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A TREATISE 



DISEASES 



NEEYOUS SYSTEM 



BY 



y<; 



WILLIAM A. HAMMOND, M. D., 

PBOFE9SOB OF DISEASES OP THE MIND AND NEBVOTTS SYSTEM AND OF CLINICAL MEDICINE IN 

THE BELLEVTJE HOSPITAL MEDICAL COLLEGE; PHY8ICIAN-IN-CHD3F TO THE NEW YOKE 

STATE HOSPTTAL FOE DISEASES OF THE NEEVOIT8 8YSTEM, ETC. 



/O 



WITH FORTY-FIVE ILLUSTRATIONS. 



" Est quoddam prodire tenus, si non datar ultra.'" 

Hoe. 




NEW YORK: 
D. APPLETON AND COMPANY, 

549 & 551 BROADWAY. 

1871. 



fi 



c^ 1 
fit** 



Entered, according to Act of Congress, in the year 1871, by 

D. APPLETON & COMPANY, 

In the office of the Librarian of Congress, at Washington. 



PEEFAOE 



In the following work I have endeavored to present a 
Treatise on Diseases of the Nervous System, which, with- 
out being superficial, would be concise and explicit, and 
which, while making no claim to being exhaustive, would 
nevertheless be sufficiently complete for the instruction and 
guidance of those who might be disposed to seek informa- 
tion from its pages. How far I have been successful will 
soon be determined by the judgment of those more compe- 
tent than myself to form an unbiassed opinion. 

One feature I may, however, with justice claim for this 
work, and that is, that it rests to a great extent on my own 
observation and experience, and is therefore no mere com- 
pilation. The reader will readily perceive that I have 
views of my own on every disease considered, and that I 
have not hesitated to express them. 

The treatise embraces an introductory chapter, which 
relates to the instruments and apparatus employed in the 
diagnosis and treatment of diseases of the nervous system, 
and five sections. Of these, the first treats of diseases of 
the brain ; the second, diseases of the spinal cord ; the 
third, cerebro-spinal diseases ; the fourth, diseases of nerve- 
cells ; and the fifth, diseases of the peripheral nerves. Dis- 
eases of the sympathetic nerve are at present so little un- 



IV PREFACE. 

derstood, if even one is recognized, that I have, for the 
present, deferred their consideration. 

I have also omitted several affections which, by some 
authors, are classed with diseases of the nervons system. 
The chief of these are cerebro-spinal meningitis, chronic 
alcoholic intoxication, and Graves's disease. The first is 
an epidemic febrile affection, similar in general features to 
typhus fever, and in which the inflammation of the menin- 
ges of the brain and spinal cord is altogether a secondary 
phenomenon ; chronic alcoholic intoxication affects the ner- 
vous system in conjunction with the organism generally, 
and is no more entitled to be considered in a work like the 
present than would be chronic poisoning from opium, hash- 
ish, mercury, or other substance ; and Graves's disease — 
although there is reason to believe that the sympathetic 
and pneumogastric nerves are implicated — is probably es- 
sentially an affection the starting-point of which is in the 
blood. 

My thanks are due to my friend Dr. R. L. Parsons, 
Superintendent of the New York City Lunatic Asylum, for 
the opportunity of selecting, from a large number of photo- 
graphs of the patients in the institution under his charge, 
such as appeared most fully to illustrate my remarks on in- 
sanity. 

The fourth volume of Prof. Austin Flint, Jr.'s, " Physi- 
ology of Man," which will be published during the coming 
season, will, with the present treatise, constitute a complete 
work on " The Physiology and Pathology of the Nervous 
System." 

162 West 34th Street, 

New York, April 20, 1871. 



OOSTEH TS. 



INTRODUCTION, ....... 9 

The Instruments and Apparatus employed in the Diagnosis 

and Treatment of Diseases of the Nervous System, . 9 

SECTION I. 

DISEASES OF TEE BRAI1T. 

Chap. I. — Ceeebeal Congestion, .... 33 

Active Cerebral Congestion. — Passive Cerebral Congestion. 
II. — Oeeebeal Anaemia, . . . . .61 

III. — Ceeebeal H^moeehage, .... 74 

IY. — Meningeal ILemoeehage, .... 114 
Hematoma of the Dura Mater. 
V. — Paetial Ceeebeal Anemia feom Obliteeation of 

Ceeebeal Aeteeies, .... 119 

' Thrombosis. — Embolism. 

VI. — Ceeebeal Softening, . 
VII.— Aphasia, 

VIII. — Acute Ceeebeal Meningitis, . 
IX. — Cheonio Ceeebeal Meningitis, 

X. TUBEECTJLAE CEEEBEAL MENINGITIS, 



XI. — Sttpptjeative Encephalitis ob Ceeebeitis, 
XII. — Diffused Ceeebeal Scleeosis, 



137 
166 
219 
231 

234 
246 
260 
278 
301 



Xin.— Multiple Ceeebeal Scleeosis, 

XIV. — TUMOES OF THE BeAIN, 

XV. — Insanity, . . . . . .324 

General Principles. — Perceptional Insanity. — Intellectual 
Insanity. — Emotional Insanity. — Volitional Insanity. — 
Mania. — General Paralysis. — Idiocy and Dementia. 



CONTENTS. 

SECTION II. 

DISEASES OF TEE SPINAL COBB. 



PAOB 



Chap. I.— Spinal Congestion, . . . . . 385 

II. — Spinal Anaemia, . . . . . 396 

Anaemia of the Posterior Columns. — Ansemia of the Antero- 
lateral Columns. 

III. — Spinal Haemorrhage — Spinal Meningeal H^moe- 

ehage, ...... 440 

IY. — Spinal Meningitis, ..... 444 

Acute Spinal Meningitis. — Chronic Spinal Meningitis. 
Y. — Acute Myelitis, . . . . .456 

YI. — Spinal Softening, ..... 463 

yii. — scleeosis of the anteeo-lateeal columns of the 

Spinal Coed, ..... 471 

VIII. — Soleeosis of the Posteeioe Columns of the Spinal 

Coed (Locomotoe Ataxia), . . . 484 

IX. — Ttjmoes of the Spinal Coed, . . . 517 

X. — Seoondaet Degeneeations of the Spinal Coed, . 523 

XI.— Tetanus, . ... . . • 529 



SECTION III. 

CEB EBRO-SP I IT A L DISEASES. 

I. — Htdeophobia, ...... 545 

II.— Epilepsy, ...... 560 

III. — Catalepsy, . . . . . .590 

IV.— Ecstasy, 597 

V.— Choeea, . . . . . . .600 

VI.— Hysteeia, ...... 619 

VII.— Multiple Ceeebeo-Spinal Soleeosis, . . . 637 

VIII. — Athetosis, ...... 654 



SECTION IV. 

DISEASES OF NEBYE-OELL8. 

I. — Atrophy and Disappeaeance of Teophio Nerve- 
Cells (Peogeessive Musculae Ateophy), . 663 



CONTENTS. 7 

PAGE 

Chap. II. — Ateophy and Disappeaeance of Motoe Neeve- 

Cell9, . . . . , .677 

Glosso-Labio-Laryngeal Paralysis. 
III. — Ateophy and Disappeaeance of Motoe and Teo- 

phio Neeve- Cells, .... 689 

Organic Infantile Paralysis. — Hypertrophy of Muscular 
Connective Tissue. 
IY. — Functional Deeangements of Motoe Nebve-Cells, 706 
Paralysis Agitans. — Writer's Spasm. — Lead Paralysis. 

SECTION V. 

DISEASES OF PERIPHERAL NERVES. 

I. — Peeipheeal Paealysis, .... 722 

Facial Paralysis. 

II. — Peeipheeal Spasm, ..... 731 

Facial Spasm. — Torticollis. 
III. — Peeipheeal Anaesthesia, . . . .735 

Anaesthesia of Cutaneous Nerves. — Anaesthesia of the 
Fifth Pair. 
IY. — Peeipheeal Hypee^sthesia (Netjealgia), . .739 

Neuralgia of the Fifth Pair of Nerves. — Cervico-Occipital 
Neuralgia. — Cervico-Brachial Neuralgia. — Dorso-Inter- 
costal Neuralgia. — Sciatic Neuralgia. 
Index, ........ 750 







Pagb 




Hammond, 


16 


. 


Mathieu, 


19 


. 


" 


20 


! J • 


Hammond, 
a 


21 
23 




Broca, 


. 195 


. 


Hammond, 


213 



LIST OF ILLUSTRATIONS. 



Fig. 

1. jesthesiometer, 

2. Dynamometer, 

3. Dynamograph, 

4. Duchexxe's Trocar, 

5. Electro-Magnetic Machine, 

6. Cerebral Convolutions, 

7. Agraphia, 

8. Dynamographic Tracing op Patient affected 

with Multiple Cerebral Sclerosis, " . 284 

9. Dynamographic Tracing of Patient affected 

with Multiple Cerebral Sclerosis, 

10. Malignant Tumor of Brain, 

11. Cerebral Aneurism caused by Embolus, 

12. Intellectual Insanity, 

13. Emotional Insanity, 

14. Acute Mania, with Mental Exaltation, 

15. " " " Depression, 

lg «( II U (( 

17. Dynamographic Tracing of Patient affected 

with General Paralysis, . 

18. General Paralysis, 

19. Idiocy, 

20. Dementia, . 

21. Chronic Spinal Meningitis, . 

22. Dynamographic Tracing of Patient affected 

with Posterior Spinal Sclerosis, " . . 491 

23. Dynamographic Tracing of Patient affected 

with Posterior Spinal Sclerosis, " . . 492 

24. Transyerse Section of Spinal Cord, LocTchart Clarke, . 506 

25. Longitudinal Section of " " . 506 



«( 




284 


Otis, . 




. 307 


Prof. W. R. 


Smith, 


316 


Hammond, 




. 350 


ii 




356 


ci 


. 


. 362 


a 


. 


364 


<( 


• 


, 365 


• 




370 


u 


. 


. 372 


(i 


. 


373 


CI 


. 


375 


.11 


. 


453 



LIST OF ILLUSTRATIONS. 



Fig. 

26. Tumor of Spinal Cord, 

27. " " " 

28. Writing of Patient affected with Mul- 

tiple Cerfbro-Spinal Sclerosis, . 

29. Athetosis, .... 

30. " (after photograph from Hubbard), 

31. Progressive Muscular Atrophy, 

32. Glosso-Labio-Lartngeal Paralysis, 

33. Writing of Patient with Glosso-Labio- 

Laryngeal Paralysis, 
84. Glosso-Labio-Laryngeal Paralylis, 

35. Muscle of Patient affected with Organic 

Infantile Paralysis, 

36. Muscle of Patient affected with Organic 

Infantile Paralysis, 

37. Muscle of Patient affected with Organic 

Infantile Paralysis, 

38. Muscle of Patient affected wieh Organic 

Infantile Paralysis, 

39. Muscle of Patient affected with Organic 

Infantile Paralysis, 

40. Muscle of Patient affected with Organic 

Infantile Paralysis, 

41. Muscle of Patient affected with Organic 

Infantile Paralysis, 

42. Hypertrophy of Muscular Connective Tissue, 

43. " " " " 

44. Muscle of Patient affected with Hyper- 

trophy of Muscular Connective Tissue, 

45. Writing of Patient affected with Writer's 

Spash, .... 



Charcot, 


• 


. 


Page 

519 

519 


Hammond, 
u 
« 

• 


• 


• 


651 
657 
661 
667 
680 


tt 

tt 


. 


• 


683 
684 


« 




• 


693 


tt 


• 


• 


694 


tt 

• 




• 


694 


tt 


• 


• 


694 


I 
tt 




• 


695 


i 
tt 


• 


• 


698 


tt 

• 

tt 
tt 


• 


• 


699 

702 

702 


tt 


• 


• 


704 


l 
ct 




• 


712 



DISEASES OF THE NERVOUS SYSTEM 



IITEODUCTIOI. 

THE INSTRUMENTS AND APPARATUS EMPLOYED IN THE 

DIAGNOSIS AND TREATMENT OF DISEASES OF TEE 

NERVOUS SYSTEM. 

Diseases of the nervous system, like those of the heart, 
lungs, and larynx, require special means of investigation and 
treatment. In no department of medical science has prog- 
ress been more decided during the last decade than in that 
class of affections considered in this treatise, and undoubt- 
edly a great deal of the advancement is due to the instru- 
ments and apparatus by which scientific research in this 
direction has become practicable. 

In the present chapter I propose to describe the instru- 
ments and apparatus employed in the diagnosis and treat- 
ment of diseases of the nervous system, and to explain the 
methods by which they are used. 

THE OPHTHALMOSCOPE. 

The ophthalmoscope consists essentially of a concave 
mirror perforated in the centre, and of a double-convex lens. 
Several modifications of this arrangement are in use, but the 
simplest instrument is, in my opinion, the best, and this is 
Liebreich's. 

It consists of a polished steel mirror about one and three- 



xii DISEASES OF THE NERVOUS SYSTEM. ■ 

quarter inches in diameter, concave, and perforated in the 
centre by a hole about the one-twelfth of an inch in diameter. 
The edges of this aperture are bevelled so as to afford as lit- 
tle obstacle as possible to the passage of the rays of light to 
the eye of the observer. 

The mirror is set into a bronze ring with a handle, and 
there is attached also to this ring a clip for holding a concave 
ocular lens, which in some conditions of refraction, either in 
the eye of the patient or that of the observer, is necessary in 
order to produce the necessary divergence of the parallel 
rays emanating from the patient's eye, and thus render the 
image of the fundus distinct. A direct image is thus ob- 
tained. The lamp, which should furnish a steady flame, is 
placed on the side of the patient's head corresponding to the 
eye to be examined, and the eye of the observer very close 
to that of the patient. This process gives a very satisfac- 
tory view of the fundus with the optic disk and retinal ves- 
sels, but requires care, and is more difficult than that by 
which the inverted image is obtained. 

In this case the observer illuminates the fundus with the 
ophthalmoscopic mirror, and then interposes between the 
mirror and the eye a double-convex lens which he holds 
lightly between the thumb and finger, resting the ring fin- 
ger on the forehead of the patient, so as to make the hand 
steady, and the little-finger being disengaged so as to be 
employed in raising the eyelid if necessary. 

The object-lens should have a focal distance of about two 
inches, and it should be held so as to bring the focus on the 
pupil. The lamp is placed behind and a little to one side 
of the eye to be examined. In order to see the optic disk, 
the patient is told to look at the ear of the observer on the 
side opposite to the eye being examined. In this way the 
axis of vision is directed inward, and the optic disk readily 
brought into view. 

These examinations are made in a room lighted only by 
the lamp used in the processes. It is sometimes necessary 



INTRODUCTION. x jii 

to dilate the pupil with atropia, in order to obtain a view of 
the disk, but experience and tact will generally enable the 
observer to dispense with this rather disagreeable procedure. 

Ophthalmoscopic examinations require the observer to 
possess a very thorough acquaintance with the anatomy of 
the eye, and also with the science of optics. Unless these 
qualifications are enjoyed, it will be much better to send the 
patient to a competent ophthalmic surgeon for an examina- 
tion, than to rush to hasty conclusions based on the most 
thorough ignorance. The real value of ophthalmoscopy in 
diseases of the nervous system is in danger of being dis- 
regarded through the sciolism of pert pretenders, who read 
papers and write memoirs without ever having seen the optic 
disk to recognize it. 

Bouchut '* gives the following list of abnormal conditions 
which are of importance in the diagnosis of diseases of the 
nervous system : 

Papillary congestion; peri-papillary congestion; papil- 
lary anaemia, partial or general ; phlebo-retinal flexuosities ; 
venous pulsation in the retinal veins ; dilatations of the reti- 
nal veins ; retinal varices ; phlebo-retinal haemostases ; phle- 
bo-retinal thromboses; phlebo-retinal aneurism; haemor- 
rhages into the retina and choroid. The diseases in which 
he thinks ophthalmoscopy is valuable as a diagnostic means 
are — the several varieties of cerebral meningitis ; cerebral 
haemorrhage ; chronic encephalitis ; cerebral softening ; me- 
ningeal haemorrhage ; chronic hydrocephalus ; tumors of the 
brain ; contusion, commotion, and compression of the brain ; 
general paralysis ; atrophy of the brain ; chronic myelitis ; 
locomotor ataxia ; tetanus ; epilepsy ; essential convulsions ; 
insanity, and several others of less importance. 

To these may be added cerebral congestion, general and 
partial ; cerebral anaemia ; and the various forms of sclerosis 
affecting the brain and spinal cord. 

1 Du Diagnostic des Maladies du Systeme Nerveux, par l'Ophthalmoscopie. 
Paris, 1866, p. 15. 



XIV DISEASES OF THE NERVOUS SYSTEM. 

CEPHALOH^EMOMETER. 

Although this instrument is intended for experiments on 
the lower animals, it enables us to arrive at very definite 
conclusions relative to the condition of the cerebral circula- 
tion. I first described it in a paper read before the New York 
Medical Journal Association in 1868, and shortly afterward 
published in the New York Medical Gazette} It was de- 
vised in somewhat different form, independently of each 
other, by Dr. S. Weir Mitchell and myself. The instru- 
ment consists of a brass tube which is received into a round 
hole made in the skull with a trephine. Both ends of this 
tube are open, but into the upper end is secured another 
brass tube, the lower opening of which is closed by a piece 
of very thin sheet India-rubber, and. the upper opening by a 
brass cap, into which is fastened a glass tube. This inner 
arrangement contains colored water. To this glass tube a 
scale is affixed. 

This second brass tube is screwed into the first till the 
thin India-rubber presses upon the dura mater, and the level 
of the colored water stands at 0, which is in the middle of the 
scale. ISTow, when the quantity of blood in the brain is in- 
creased, the liquid rises in the tube, being pressed upward 
by the elevation of the thin rubber closing the lower open- 
ing ; when the quantity of blood is lessened, the liquid falls 
by its own gravity. 

It was by this instrument that I was enabled to demon- 
strate, in the most conclusive manner, that during sleep the 
amount of blood circulating in the cerebral vessels is much 
less than during wakefulness. 8 

^STHESIOMETEE. 

The sesthesiometer is an instrument for the purpose of 
determining the degree of tactile sensibility possessed by the 

* x Also, Journal op Psychological Medicine, January, 1869, p. 47. 
2 Sleep and its Derangements. Philadelphia, 1869, p. 317. 



INTRODUCTION. xv 

patient. The instrument was devised in 1858 by Dr. Sie- 
veking, 1 of London. Its value in cases of aberrations of sen- 
sibility depends upon the fact, ascertained by Dr. E. H. 
"Weber, that the capability of distinguishing two impres- 
sions made upon the skin simultaneously, varies in different 
regions of the body according to the distance they are apart. 
In sensitive regions, as the end of the finger, the two points 
of a pair of dividers can be distinguished at about the 
twelfth of an inch apart, while in the middle of the back 
only one point is felt, though they are two inches apart. 
In accordance with this principle, the sesthesiometer is used 
to determine the sensibility of the skin in various diseases, 
it being well known that this is subject to variation. 

Thus when the sensibility is intact, two points, touch- 
ing the back of the hand at the same time, can be distin- 
guished as two points when separated an inch. If, in 
examining a patient, we should find that, when the two 
points were two inches apart, the patient felt but a single 
impression, we should know that he had lost sensibility in 
the cutaneous nerves of that part of the body. 

Dr. Sieveking's sesthesiometer is nothing more than a 
beam-compass. It consists of a rod of bell-metal four inches 
in length, graduated into inches and tenths of an inch. At 
one end is a fixed steel point ; another steel point is made to 
slide upon the beam, and can be fixed at any distance from 
the first by a screw which works at the top of the slide. 

In 1861 2 1 described an sesthesiometer which I believe 
was the first used in this country. It consisted of a pair of 
dividers, to one arm of which the arc of a circle, in brass, 
was affixed. This arc was divided so as to measure tenths 
of an inch. A short time since, I suggested to Mr. Stohl- 
man, the instrument-maker, a modification of this instru- 
ment, which for convenience is, I think, superior to all 

1 Brit, and For. Med.-Chir. Rev., January, 1858, p. 281. 

2 A Clinical Lecture on Chronic Myelitis. Delivered in the Baltimore Infirm- 
ary, March 16, 1861. American Medical Times, January 8, 1861, p. 379. 



XVI 



DISEASES OF THE NERVOUS SYSTEM. 



others. This, as closed, for the pocket-case, and open, as in 
use, is seen in the accompanying woodcut (Fig. 1) l and 
need not be further described. 



>|-|'l-ltll Ml l-IZl|.|lll(\llMl|'lfrlll I-'IMSI I I 




The minimum normal distances at which the two points 
of the sesthesiometer can be distinguished in different regions 
of the body are stated in the following table : a 

Point of the tongue £ a line. 

Palmar surface of the third finger 1 " 

Red surface of the lips 2 lines. 

Palmar surface of second finger 2 " 

Dorsal surface of third finger 3 " 

Tip of the nose . . 3 " 

1 First described by me in the Journal of Psychological Medicine, Octo- 
ber, 1868, p. 830. 

2 This table is quoted from Miiller s Philosophy, translated by Baly. Lon- 
don, 1840, p. '752. 



INTRODUCTION. xvii 



The palm over the heads of the metacarpal bones 3 lines. 

Dorsum of tongue, one inch from the tip 4 

Part of the lips covered by the skin 4 

Border of the tongue, an inch from the tip 4 

Metacarpal bone of the thumb 4 

Extremity of the great- toe 5 

Dorsal surface of the second finger 5 " 

Palm of the hand 5 " 

Skin of the cheek 5 " 

External surface of the eyelids 5 " 

Mucous membrane of the hard palate 6 " 

Skin over the anterior surface of the zygoma 7 " 

Plantar surface of the metatarsal surface of great-toe. . 7 " 

Dorsal surface of the first finger 7 " 

On the dorsum of the hand over the heads of the meta- 
carpal bones 8 " 

Mucous membrane of the gums 9 " 

Skin over the posterior part of the zygoma 10 " 

Lower part of the forehead' 10 " 

Lower part of the occiput 12 " 

Back of the hand 14 '• 

Neck under the lower jaw 15 " 

Vertex 15 " 

Skin over the patella 16 " 

" " " sacrum 18 " 

" " " acromion 18 " 

The leg, near the knee and foot 18 " 

Dorsum of the foot, near the toes 18 •* 

The skin over the sternum - 20 " 

" " " " five upper vertebrae 24 " 

" " " " spine near the occiput 24 " 

" " in the lumbar region 24 " 

" " " ". middle of the neck 30 " 

" " over the middle of the back 30 " 

The middle of the arm 30 " 

" " " « thigh 30 " 

THERMOMETER. 

The thermometer is of use for the purpose of determining 
variations of temperature in different parts of the body. It 
should be graduated in tenths of a degree, and be held upon 



xviii DISEASES OF THE NERVOUS SYSTEM. 

the part subjected to examination so long as the mercury 
continues to rise or fall. Comparative determinations must 
be made under precisely similar conditions. 

becquerel's disks. 

By means of these little instruments very slight varia- 
tions of temperature can be ascertained. They consist of an 
extremely thin plate of copper, about the size of a half-dime, 
soldered to a thin rod of bismuth. This latter is contained 
in a small tube of hard rubber furnished with a handle. 
The disks are two in number, and by means of delicate silk- 
covered wires are in communication with the poles of a gal- 
vanometer. If a lower extremity, for instance, is subjected 
to examination, one of the disks is placed upon it and the 
other upon the corresponding part of the other limb. If the 
temperature of both limbs be the same, the needle of the 
galvanometer remains quiet ; if either be warmer than the 
other, the needle is deflected to the north or south according 
as one or the other limb has the higher temperature. By 
this apparatus very much less than the hundredth of a degree 
of temperature can be determined with absolute accuracy. 1 

THE DYNAMOMETER. 

Several forms of an instrument for measuring the strength 
of patients have been devised. The best and most generally 
applicable is that of M. Mathieu, an instrument-maker of 
Paris. It is very simple, and for measuring the strength of 
the hands leaves nothing to be desired. 

It consists, as is shown in the cut (Fig. 2), of an ellipti- 
cal steel spring, to which is attached a semicircle of gilt brass, 
upon which a scale is marked. An indicator, terminating 
at one end in a cog-wheel, is capable of being moved freely 
around the arc of the circle by a steel arm, upon one side of 
which, cogs, fitting into those of the indicator, are cut. One 

1 See my memoir on the Pathology and Treatment of Organic Infantile Pa- 
ralysis, in Journal op Psychological Medicine, No. 1, July, 1867, p. 53. 



INTRODUCTION. ^ 

end of this arm (the lower) touches the elliptical spring, 
when the indicator points to the zero of the scale ; a brass 
sheath upon the under side of the scale keeps this arm in 
place, at the same time allowing it to move freely. 

Fig. 2. 




When the dynamometer is taken into the hand and 
pressed, the two sides of the spring are approximated and the 
steel arm, with the cogs being pushed by the lower side of 
the spring, turns the indicator. One great advantage of this 
instrument is that, when the pressure is taken off, the indica- 
tor does not return to the zero, but remains at the point to 
which it has been carried by the muscular power of the in- 
dividual. We are thus enabled to see the extent of his 
strength, after he has made his effort, and do not have to 
watch him while he is using the instrument. It will also 
be seen that this dynamometer can be used to measure tac- 
tile force ; for if two hooks with cords attached be fastened 
to the spring at the points a and h, traction on the cords 
will approximate the two sides of the ellipse, and thus push 
the steel arm so as to move the indicator as before. 

THE DTNAMOGRAPH. 

This instrument, which is of great value in the diagnosis 
of diseases of the nervous system, is shown in Fig. 3. 

It consists of the dynamometer B B, to which a toggle- 
joint, moving a steel rod, is attached. This steel rod plays 
through a hole in the end of the elliptical spring and moves 
the lever which raises the pencil D. At A is a screw which 



XX 



DISEASES OF THE NERVOUS SYSTEM. 



varies the point at which the rod touches the lever, and thus 
increases or lessens the delicacy of the indications. C is a 
silvered plate upon which the paper is fastened by clips. 
To the lower part of this plate, a strip of gilt brass, with cogs 
cut in it, is attached. E is a gilt-brass box containing a 
watch movement like that of the sphygmograph. A cog- 
wheel which projects above the upper side of this box fits 
into the cogs on the plate which carries the paper. The 



Fig. 3. 




wheel for winding up the clock- wort, and the wire for stop- 
ping it, or setting it in motion, are not seen in the figure, 
they being on the opposite side of the box. 

To set the instrument in action, the sphygmograph 
movement is attached to the dynamometer at A. The clock- 
work is then wound up, and the plate holding the paper 
placed in the groove on top of the box E. The dyna- 
mometer is then grasped by the hand and squeezed firmly ; 



INTRODUCTION. xxi 

the lever is thus moved, and the plate with the paper is 
carried along by the cog-wheel. As it moves, the pencil 
traces a line on the paper, the height and regularity of which 
depend upon the firmness and steadiness with which the 
dynamometer is pressed. As seen in the cut, the plate with 
the paper is in motion, and has about half completed its 
course. The patient should not look at the paper while 
using the instrument. 

The dynamograph, therefore, writes down the muscular 
power and tone of the individual, and likewise indicates the 
perfection of what is sometimes called the muscular sense. 
A person in good health will make a straight line with the 
pencil. If there is paralysis of the muscles of the arm, or 
incoordination to the slightest possible extent, the line will 
be irregular. The papers used may be marked with the date 
and the name of the patient, and thus a record of his condi- 
tion is preserved. 

The pencil should be of the very softest lead, and the 
paper should be rough and unsized. 1 



This very useful little instrument is shown in Fig. 4. 
It is introduced open as at a. When it has perforated the 



Fig. 4. 




muscle under examination, the small button at the under 
part of the handle is pushed forward ; this propels a half- 
cylinder of steel against the shoulder at the end of the tro- 

1 The first account of the use of the dynamograph was given by myself in 
the Journal op Psychological Medicine, January, 1868, p. 139. 



Xxii DISEASES OF THE NERVOUS SYSTEM. 

car, and thus a small piece of muscle is detached and caught 
in the cavity. The lower figure b represents the instru- 
ment ready to be withdrawn. By drawing the button 
back, the bit of fibre can be taken out, and is then ready 
for microscopical examination. 

ELECTEICAL APPARATUS. 

The electrical apparatus required in the diagnosis and 
treatment of diseases of the nervous system must be of two 
kinds : one for furnishing the primary or galvanic current, 
the other for yielding the induced or faradaic current. 
Among the machines of the first category are those of 
Stohrer, which are now made very satisfactorily by the 
Galvano-Faradaic Manufacturing Company of New York, a 
combination of Smee's cells which is manufactured by Dr. 
Jerome Kidder, Electrical Mechanician to the New York 
State Hospital for Diseases of the Nervous System, and 
Daniell's batteries, which can be obtained of any electrical- 
instrument maker. My own preference is for Kidder's 
arrangement, which gives a very equable current and causes 
very little trouble. 

Of induced-current batteries I have on several occasions 
before this commended those of Kidder, which are certainly 
very admirable instruments. Recently, however, I have 
used with great satisfaction an apparatus which is figured 
in the accompanying woodcut (Fig. 5), which represents the 
Portable Excelsior Electro-Magnetic Machine manufactured 
by the Galvano-Faradaic Manufacturing Company, with all 
the new improvements attached. This figure represents a 
double-cell battery : 

A. The graduated hinged battery-rod, to the lower end 
of which the zinc plate is attached ; the hinge enables the 
rod to be laid over horizontally when the battery is not re- 
quired for action, thereby preventing an accidental immer- 
sion of the zinc plate into the battery-fluid. The graduated 
points on the rod exhibit the depth to which the zinc, when 



INTRODUCTION. xx iii 

the rod is raised vertically and lowered down, becomes im- 
mersed in the fluid, and indicates the battery-power obtained. 
It can be retained in situ at any desired depth by means of 
the binding screw. The brass spring 1 presses against the 
thumb-screw of the rod when this is fully down in the cell, 
and thereby maintains its conducting power, which becomes 
deteriorated if it is not kept free from acid, and perfectly 
clean. 

Fig. 5. 




B exhibits a combination of a movable platina disk, 
with that part of the retracting armature lever which plays 
against the adjusting-screw connecting it with the battery. 
After continued use this point of the disk becomes oxidized 
by the electric spark. When this happens, the shocks will 
be irregularly generated. The disk can be turned a very 



xx iv DISEASES OF THE NERVOUS SYSTEM. 

little round on its pivot, whereby a fresh surface of its 
periphery will be brought to play against the point of the 
adjusting-screw. 

0. The rheotome, or adjustable elastic fork. Its free 
end embraces the vibrating armature-spring or lever D be- 
tween its prongs, so as to control the extent of the vibrations. 
When the rheotome is depressed, the upper end of the lever 
can vibrate freely. When it is raised, its prongs will, in 
proportion to the extent of its elevation, limit the space 
for the vibrations, and consequently increase their rapidity. 
The control of the velocity of the vibrations is of great im- 
portance in therapeutics and the diagnosis of disease. 2 is 
a set screw, placed to work against the elastic fork, and reg- 
ulate its position laterally, with reference to the lever D. E 
represents the rheotrope or current-changer, between the 
electro-magnetic machine and the electrodes, by which the 
course of the primary and secondary currents can be in- 
stantly changed without moving the conducting wires. F 
represents the hydrostat or metallic capping, with stanch- 
ions or binding-straps and thumb-screws 3 3 attached. In- 
terposed between the hard-rubber covering plate and top of 
the battery-cell is a soft-rubber packing. This capping can 
be tightened to the desired extent, by means of the thumb- 
screws 3 3 ; thus preventing the spilling or splashing over of 
the liquid, impeding evaporation, maintaining the strength 
of the battery-fluid, and maintaining the cells steadily in 
their proper places. The hydrostat overcomes the great 
difficulty hitherto experienced with all electric machines in 
which liquids are used. By means of this invention they 
are now rendered portable, and can be carried around 
charged and ready for use, without danger of spilling the 
battery-fluid. G represents an indicator or scale, affixed 
beneath the movable coil 4, in English and French measure- 
ment, graduated both ways, to enable the practitioner to 
make exact record of the intensity of the electricity applied 
to his patients at each seance; so determines the different 



INTRODUCTION. xxv 

degrees of susceptibility evinced on each occasion. As the 
strength of the primary current is increased by drawing out 
the movable coil 4, we count from left to right, when we 
apply that current. The intensity of the secondary current 
is increased by pushing inward the movable coil 4 ; in this 
case, we made our record from right to left. These machines 
are fitted up in black-walnut cases, with handles and locks 
attached. 

Nothing can exceed the efficiency and convenience of 
this instrument. It possesses the great advantages of sup- 
plying both the inducing and induced currents, and enabling 
the physician to regulate the interruptions so as to give the 
shocks very slowly, a matter of great importance in the 
treatment of paralytic disorders. 



SECTION I. 
DISEASES OF THE BKAIK 



CHAPTEE I. 

CEREBRAL CONGESTION. 

Cerebral congestion is of two kinds, which differ as re- 
gards their mode of origin and symptoms. In the active 
form, there is an increase in the amount of arterial blood cir- 
culating in the vessels of the brain ; in the passive, the quan- 
tity of venous blood is augmented. Occasionally the two 
conditions coexist. 

ACTIVE CEREBRAL CONGESTION. 

This is much the more common form. Of six hundred 
and twenty-two cases recorded in my note-book, as occurring 
in my private practice, five hundred and seven were of this 
description. 

Andral recognized eight varieties, all of which may, with 
advantage, be comprehended in three, which are appropri- 
ately designated from the chief feature characterizing the 
attack, namely, the apoplectic, the epileptic, and the mani- 
acal. Either of these may occur with scarcely a moment's 
warning. Generally, however, there is a premonitory or 
first stage, the symptoms of which, though well marked, are 
3 



34: DISEASES OF THE BRAIN. 

not peculiar exclusively to any one of the fully-established 
conditions mentioned. It is therefore impossible to predict 
with accuracy, from the symptoms of this prodromatic stage, 
whether the apoplectic, the epileptic, or the maniacal form, 
will be developed. An attentive study of this stage should 
always be made, and active measures taken for the relief of 
the patient at a time when success can generally be obtained. 

Symptoms. First Stage. — Among the earliest symptoms 
of active cerebral congestion, wakefulness is especially no- 
ticeable, and may be for a time the only evidence of disorder 
which attracts the attention of the patient. He goes to bed 
feeling weary, and as if sleep would very quickly overtake 
him, but he is disappointed, for he obtains but an hour or 
two of unquiet slumber, which is generally broken by un- 
pleasant dreams. During the remainder of the night he 
tosses restlessly from side to side of the bed, his mind either 
occupied by the thoughts which have occurred to him through 
the day, or else filled with the most preposterous ideas. He 
consequently rises unrefreshed, feverish, and ill-prepared for 
either mental or physical exertion. 1 So far as the mind is 
concerned, there is an inability to give the attention to any 
subject requiring much thought, and at times an absolute 
want of power to get correct ideas of even simple matters. 
This is especially seen in those who have arithmetical ques- 
tions to solve, or long columns of figures to add up. Indeed, 
mental labor of all descriptions is not only difficult, but is 
irksome in the extreme. 

Before long the evidences of intellectual derangement 
become more evident. The ideas are confused and without 
logical arrangement ; the memory begins to fail, especially in 
regard to recent occurrences ; and there seems to be a special 
proclivity to forget words, and to substitute others having a 
similar sound when pronounced, or appearance when written. 

1 For a more complete account of wakefulness in all its relations, see the 
author's treatise on "Sleep and its Derangements." J. B. Lippincott & Co., 
Philadelphia, 1870, 



CEREBRAL CONGESTION. 35 

The names of persons and places are particularly difficult to 
recollect. The judgment is weak and vacillating ; the most 
strongly-expressed determination is changed apparently 
without reason, and again there may be an impossibility of 
arriving at a decision in cases where ordinarily but little re- 
flection would be necessary. Any effort toward continuous 
or severe thought increases the difficulties of the mind, and 
augments the pain or uneasiness which generally exists in 
the head. Illusions, hallucinations, or delusions, may be 
present, but are not usually fixed ; and the patient will often 
laugh at the absurd images he has seen, or ideas he has en- 
tertained not five minutes before. Persons thus affected will 
frequently reason clearly in regard to apparitions or voices, 
of the unreality of which they are fully sensible. 

The emotional system participates in the general mental 
disturbance, and the passions are thus easily roused into ac- 
tivity by slight exciting causes. Trifling circumstances 
produce great annoyance, and the little every-day troubles of 
life appear of vast importance. The disposition accordingly 
becomes suspicious, peevish, and fretful. 

In conj unction with these mental phenomena, there are cer- 
tain physical symptoms of disordered cerebral action. Thus 
there are pain, heat, a feeling of fulness or distention in the 
head, or the sensation as if a tight band encircled it. Vertigo 
is very generally complained of, and may be so severe as to 
prevent the patient moving about. In some cases headache 
constitutes the chief feature of the disorder, and is almost 
constantly present. There are noises, such as roaring, rum- 
bling, and ringing, in the ears, and occasionally loud reports 
such as those produced by the discharge of fire-arms. Some- 
times there are bright flashes of li°;ht from over-excitation of 
the retinae, and at others dark spots — muscce volitantes — ren- 
der the vision indistinct. Ophthalmoscopic examination, 
which should never be omitted, shows the vessels of the 
retina to be increased in number, diameter, and tortuosity, 
and occasionally the optic disk is found more or less con- 



36 DISEASES OF THE BRAIN. 

gested. The conjunctivae are suffused, the pupils are con- 
tracted, there is intolerance of light, and motion of the eye- 
balls is painful. Loud noises are likewise disagreeable. The 
face is flushed, the carotids and temporals throb with more 
than ordinary force, and there may be involuntary twitching 
of one or more of the facial or other muscles. Bleeding from 
the nose is not infrequent. 

Sensation and the power of motion are usually affected, 
and generally, though not always, on one side of the body 
only. Thus the arm or the leg feels heavy, and a sensation 
as of ants crawling over it, pins and needles sticking in it, or 
as if the limb is " asleep," is experienced. These abnormal 
sensations may be restricted to the face or the trunk. Ex- 
amination with the sesthesiometer shows that the ability to 
distinguish the two points of the instrument at the normal 
distance apart is less on the affected side than on the other, 
and that thus to get the sensation of two points they must 
be more widely separated when applied to the diseased side 
than is necessary for the corresponding parts of the sound 
side. The muscular strength is also lessened generally, but 
sometimes the difficulty is especially noticed in particular 
muscles, such as the tibialis anticus or the deltoid, which, los- 
ing a portion of their contractile power, cause the patient to 
experience an awkwardness in raising the foot, or elevating 
the arm from the side. The face, however, is rarely affected, 
even when the muscular power is diminished on all the rest 
of one side of the body, and the tongue, when protruded, 
comes out straight. Careful observation will generally de- 
tect some difficulty, perhaps slight, about the speech. Words 
are not pronounced with as much distinctness as before, es- 
pecially when the patient is fatigued or has been speaking 
for some time. The Unguals and labials among letters are 
particularly troublesome, as well as all words which require 
the nice management of the end of the tongue for their enun- 
ciation. The articulation is thick, and sometimes whole syl- 
lables are slurred over in a slovenly way. 



CEREBRAL CONGESTION. 37 

The other organs of the body are more or less deranged. 
The pulse is unusually slow and full, the appetite capricious, 
the digestion imperfect, the bowels costive, and the urine 
scanty and high colored. 

The foregoing constitute the ordinary assemblage of symp- 
toms which are first met with in congestion of the brain. 
Some of them may be absent, others so slightly manifested 
as to escape ordinary observation, and others again so strong- 
ly exhibited as to excite the grave apprehensions of the pa- 
tient and his friends, and to require him to keep his bed. 
Generally, however, they are not so severe as to prevent him 
attending in a measure to his ordinary avocations, and they 
may altogether disappear either spontaneously or in conse- 
quence of appropriate medical treatment. 

A spontaneous cure is, however, rare, and without proper 
management on the part of the patient or his medical at- 
tendant the symptoms pass sooner or later into one of the 
fully-developed forms mentioned. Thus, of the five hundred 
and seven cases already cited, the disease was arrested at the 
first stage in four hundred and seventy-eight by appropriate 
treatment, while there was not a single instance of sponta- 
neous cure. 

Second Stage, a. The Apoplectic Form. — Occasionally 
this variety of cerebral congestion is initial, but ordinarily 
it is preceded by the group of symptoms just detailed. In 
either event the onset is generally sudden. The patient is 
perhaps walking in the street, when he staggers, loses con- 
sciousness, and falls. The loss of intelligence and sensibility 
is, however, rarely complete, and may last but a few min- 
utes or even seconds, though sometimes continuing for sev- 
eral hours. 

Paralysis to a greater or less extent is always present for 
a time. One limb only may be affected or those of one side, 
or all four members. It is never complete, the patient being 
able to perform some movements, though not to exert his 
fall strength. The face is rarely involved, and the patient, 



38 DISEASES OF THE BRAIN. 

though answering briefly when addressed in a loud voice, 
speaks indistinctly and with difficulty. 

The respiration is loud, slow, but rarely stertorous, and 
it is not often that there is puffing of the lips and cheeks. 

The pulse is slow, hard, and full. Sometimes the face 
is flushed, and sometimes it is unusually pale. The sphinc- 
ters generally retain their power. 

The senses, though weakened, are often capable of being 
exercised by tolerably strong excitations. A bright light 
causes uneasiness and closure of the eyelids. A loud noise 
is productive of discomfort, and a limb, when pinched, is with- 
drawn. 

The power of the mind is greatly lessened, and some fac- 
ulties are altogether abolished. Answers more or less direct 
are given to simple questions put in a loud tone, but even 
moderate intellectual action seems to be impossible. 

Gradually the attack passes off, leaving the patient in a 
state of mental and physical depression, which may last for 
several days. The paralysis usually entirely disappears, but 
occasionally it does not, one or more limbs or muscles re- 
maining permanently, or for a long time, disabled. 

It sometimes happens, however, that the termination is 
not so favorable. The vessels may remain congested, serum 
may be effused, and death may result without there being any 
vascular lesion. Two cases have come under my notice, in 
which death ensued from this cause in first attacks. 

. A person who has once had a paroxysm, such as has been 
described, is thereby rendered more liable to subsequent seiz- 
ures, each one of which still further permanently impairs his 
mental and physical powers. In one case, occurring in my 
practice, there have been eleven attacks in five years ; and in 
another, fourteen in four years. In both of these, and in sev- 
eral similar instances I have witnessed, there was paralysis, 
which had become more profound with each accession. It is 
therefore inexact to say, as do some writers, that the paralysis 
of cerebral congestion always disappears in a short time. 



CEREBRAL CONGESTION. 39 

Of twenty-nine cases of fully-developed, active cerebral 
congestion of which I have notes, sixteen were of the apo- 
plectic form. 

b. The Epileptic Form. — This, like the variety just de- 
scribed, may come on suddenly, or may be preceded by pre- 
monitory symptoms. The phenomena of the attack do not 
differ from those attendant on an ordinary epileptic parox- 
ysm, except that there is never an aura, and no peculiar cry, 
such as is so often met with in pure epilepsy. There is the 
same tonic spasm, followed by clonic convulsions, which may 
or may not be confined to one side of the body, and which 
may or may not be followed by temporary or long-continued 
paralysis. Stupor likewise supervenes, but is neither of so 
long a duration nor so profound as in true epilepsy. 

This form of cerebral congestion never occurs during 
sleep, for then the brain contains less blood than when the 
individual is awake. It may occur during stupor induced 
by certain drugs, constriction of the neck, or the dependent 
position of the head ; but stupor is not sleep, although the 
two conditions are frequently confounded. Epilepsy occur- 
ring during ordinary sleep is never the result of congestion. 
This point will be more fully considered under the head of 
epilepsy. 

After the stupor the patient may feel comparatively well, 
or there may be delirium continuing for several hours. As 
in the apoplectic form, there may be a succession of attacks, 
and the mind and physical power of the patient are thereby 
greatly weakened. 

The variety under consideration is, perhaps, more liable 
to occur in individuals past the age of forty, though I have 
witnessed several cases in quite young persons. It is not 
often met with in old age, and, when it is, is generally fatal, 
probably from secondary lesion. Nine of the fully-developed 
cases, of which I have record, were epileptic in character. 

c. The Maniacal Form. — This variety, though not so 
common as either of the others, is yet not infrequent. It is 



40 DISEASES OF THE BRAIN. 

characterized by an accession of mental derangement not 
materially different from that indicative of acute mania. 
The delirium is of a very active character, the eyes are suf- 
fused, the face is red, the head hot, the motility active, and 
the whole manner, character, disposition, and mental pro- 
cesses are changed. During the paroxysm the patient may 
commit some crime of violence, and it almost always happens 
that his combative proclivities are aroused. He may like 
wise attempt to injure himself. 

The attack may come on with great suddenness. In the 
case of a gentleman recently under my charge, it was the re- 
sult of eating a hearty meal in a great hurry at a railway 
station. A few minutes after his return to the train he was 
attacked with furious delirium, during which he attempted 
to injure himself and all within his reach. He was seized 
and held, but continued, as far as he was able, to bite, scratch, 
and kick at those who were near him. The paroxysm lasted 
about two hours. He then fell into a heavy stupor, from 
which he did not arouse for two hours longer. For several 
days his mind was weak, and there was numbness in vari- 
ous parts of his body. Gradually, however, he regained his 
former powers, but he suffered from occasional confusion of 
thought and difficulty of speech, with headache and wake- 
fulness for several weeks. 

Paralysis, as in the other two forms, may be one of the 
phenomena of this variety of cerebral congestion. 

Death may take place during the attack, or from second- 
ary lesions afterward. 1 Of the twenty-nine fully-developed 
cases, four were of the maniacal form. 

What is called temporary insanity, mania ephemera, or 
impulsive insanity, generally depends upon cerebral conges- 
tion. The subject, therefore, is of vast importance in its 
medico-legal relations. 8 

1 The whole subject of cerebral congestion has been well considered by Cal- 
meil in his " Traite des Maladies Inflammatoires du Cerveau." Paris, 1859. 

2 See a memoir by the author, entitled " A Medico-Legal Study of the Case of 



CEREBRAL CONGESTION. 41 

Third Stage. — This period in ay be considered as begin- 
ning after the immediate effects of the paroxysm, whether it 
has been of the apoplectic, epileptic, or maniacal form, have 
passed off. It is characterized by feebleness of body and 
mind, by gastric or intestinal derangement, by pain in the 
head with transient attacks of vertigo, and occasionally by 
numbness and slight paralysis of one or more of the limbs. 
Many of the symptoms met with in the first stage are again 
found in this. 

But the principal phenomena are those connected with 
secondary lesions, such as inflammation, abscess, softening, 
and adventitious growths of various kinds. These will be 
considered under their proper heads. 

It must not be forgotten that one circumstance always 
exists, and that is, the proclivity to other paroxysms of some 
one of the fully-developed forms. 

PASSIVE CEREBRAL CONGESTION. 

This condition is the result of causes which increase the 
amount of venous blood in the brain. It is more commonly 
met with in old persons. One hundred and fifteen cases out 
of six hundred and twenty-two, occurring in my practice, 
were of this form. 

Symptoms. First Stage. — As in active cerebral conges- 
tion, there is a premonitory stage, the symptoms of which 
are similar to those previously described. There is, however, 
a tendency to stupor, and the other phenomena are, in the 
main, less strongly marked. Yertigo, pain, illusions, halluci- 
nations, and delusions, are nevertheless generally present at 
one time or another. But the stupor or tendency to somno- 
lence is the most prominent feature, and the sleep, even when 
comparatively natural, is attended with dreams unpleasant 
or even frightful in character. 

Daniel McFarland," in the Journal of Psychological Medicine for July, 1870. 
Also published separately by D. Appleton & Co. New York, 1870. 



42 DISEASES OF THE BRAIN. 

The degree of congestion may be suddenly increased, or, 
what is a more probable sequence, there may be effusion of 
serum, and then the second stage exhibiting itself either in 
the apoplectic, the epileptic, or the maniacal form results. 

The proportion of cases of passive cerebral congestion 
which pass to the second stage is greater than in the active 
form of the affection. Thus, of the one hundred and fifteen 
cases cited, thirty-one went on unchecked to the second 
stage. 

Second Stage, a. The Apoplectic Form. — Though this 
variety may be developed suddenly as in active cerebral con- 
gestion, it usually is more slowly evolved. In this latter 
case a general numbness is commonly the first symptom, and 
the drowsiness gradually increases. At first it is easy to 
rouse the patient from this stupor, but eventually it is more 
difficult, and at times impossible. The faculties of the mind 
may likewise, at the beginning, be excited into a moderate 
degree of activity, but with the advancing coma they are no 
longer manifested. The cutaneous sensibility becomes less 
and less ; the urine dribbles, from paralysis of the bladder 
and its sphincter ; arid the bowels, if not obstinately consti- 
pated, allow their contents to pass involuntarily. 

This condition may last for several weeks, and, though 
recovery may take place, this is never complete. It gener- 
ally ends in death. 

Nine cases of the thirty-one were of this character. 

b. The Epileptic Form. — This may not differ materially 
from the epileptic form of active congestion except as regards 
increased length of the fit and prolonged stupor. Gener- 
ally, however, there is a repetition of the convulsive seizures, 
and I am led to believe from my experience that there is a 
greater tendency to biting the tongue. Paralysis is a more 
common sequence, and is of longer duration. 

Nineteen cases of the thirty-one were epileptic in form. 

c. The Maniacal Form is not often met with in passive 
cerebral congestion, and, when it is, the delirium, so far from 



CEREBRAL CONGESTION. 43 

being of a furious type, is low. The patient mutters to him- 
self incoherently and exhibits great muscular restlessness, but 
never attempts to do violence to himself or others. Coma 
often occurs as a sequence. Three cases were of this type. 

Causes. — The canses of cerebral congestion are : of the ac- 
tive form, those influences which are capable of increasing 
the quantity of arterial blood in the brain ; of the passive, 
those which produce a similar effect upon the amount of ve- 
nous blood circulating in the vessels within the cranium. 
The causes of the first category induce activity of circulation, 
those of the second torpidity. 

The causes of active cerebral congestion may either 
by their gradual operation initiate the premonitory stage, or 
they may suddenly induce the development of this stage into 
one or other of the varieties already described as constituting 
the second stage. Among them are temperature either very 
high or very low. Thus the disease is more frequent in hot 
climates than in those of more temperate character, and in 
the summer months than in the spring or autumn. It is, 
however, more common in very cold than in warm weather. 
Thus Andral, of one hundred and fourteen cases, found that 
twenty-six occurred in summer and fifty in winter. My own 
experience is to the same effect, as will be seen from the fol- 
lowing table, which embraces the cases in my private prac- 
tice in the city of New York during a period of five years, 
beginning January, 1865, and ending December, 1870 : 

January 6Q July 68 

February 64 August 74 

March 50 September 27 

April 39 October 31 

May 42 November 52 

June 37 December 72 

Total 622 

An examination of this table shows that one hundred and 
ten cases occurred in the autumn months, one hundred and 



44: DISEASES OP THE BRAIN. 

thirty-one in the spring, one hundred and seventy-nine in 
summer, and two hundred and two in winter. 

Passive cerebral congestion is very much more frequent 
in cold than in warm weather. 

The direct rays of the sun are capable of producing sud- 
den attacks (insolatio), of which congestion is a prominent 
feature, but which require separate consideration, and it is 
not uncommon for artisans, whose heads are exposed to heat 
from furnaces, to suffer in a similar manner. 

Some authors contend that certain winds increase the 
liability to cerebral congestion. Leuret, quoted by Mos- 
mant, 1 could attribute an epidemic of cerebral congestion 
which appeared at Charenton to nothing but a long-con- 
tinued wind from the northwest. The supposition that 
atmospheric electricity is a causative influence rests upon 
nothing but hypothesis. 

The ingestion of a large quantity of food into the stomach 
may occasion passive congestion by the pressure which the 
distended organ makes upon the large veins of the abdomen. 
Rapid eating, even though the quantity of food be moderate, 
may cause the active form of the affection by some influence 
exerted through the sympathetic system. 

Sudden and violent physical exertion, especially if made 
in the stooping posture, is very liable to induce cerebral con- 
gestion. Child-birth is an instance in point, and I have 
known several cases to be caused by severe straining in the 
water-closet. The constipation of the bowels rendering such 
efforts at defecation necessary, is itself productive of the 
disease. 

A dependent position of the head and constriction of the 
neck from the dress are also, by impeding the return of blood 
from the head, liable to induce congestion of the passive form. 

Certain articles of food and medicine, such as spices, al- 
coholic liquors, opium, belladonna, quinine, etc., act either 
by augmenting the action of the heart, or by their influence 

1 Essai sur la Congestion Cerebrate. Paris, 1858. 



CEREBRAL CONGESTION. 45 

on the sympathetic, paralyzing the yaso-motor nerves, and 
thus increasing the calibre of the cerebral blood-vessels. 

Tumors in the neck, or in other parts of the body where 
the return of blood from the head may be impeded by their 
pressure, likewise cause congestion. Other causes are to be 
found in certain diseases, as fevers of various kinds, erysipelas, 
disorders of menstruation, the suppression of hemorrhagic 
or other discharges ; local affections of the brain, as embolus, 
thrombosis, tubercle or apoplectic clots, and sympathetically 
by worms in the intestinal canal, or irritation existing in 
other portions of the system. 

But the most influential and common causes of cerebral 
congestion are to be found in long-continued intellectual ex- 
ertion, mental anxiety, or sudden, violent, or prolonged emo- 
tional disturbance. It is from the action of such factors 
that the premonitory symptoms are generally induced, though 
they may, especially those embraced in the last-named cate- 
gory, immediately develop a fully-formed attack. The fact 
that cerebral exercise increases the amount of blood in the 
head is made evident to all of us at times by the distention 
of the superficial vessels, the suffusion of the eyes, the heat 
and pain which we feel when we have overtasked our brains. 
Cerebral action is always attended with hyperemia, just as 
is the activity of the liver, the kidneys, or other organs. Ac- 
tive cerebral congestion is thus induced, and is within cer- 
tain limits perfectly normal. But these limits are liable to 
be exceeded, and in this active period of the world's history 
often are, and then the condition described as the first stage 
of congestion is established. The vessels, from continued 
overdistention, lose their contractility, just as does the india- 
rubber band, used to keep a bundle of letters together, when 
the package is too large or it has been kept stretched for a 
long time. An additional disturbing force, heat, cold, an 
overloaded stomach, increased mental labor, emotional ex- 
citement, or any of the causes mentioned, may suddenly 
evolve a fully-developed paroxysm. 



46 DISEASES OF THE BRAIN. 

Emotion acts in a similar manner, though, as has been 
said, often with more suddenness. The emotions of shame, 
of anger, and others, cause the face to become red from dila- 
tation of the blood-vessels, and a like effect is produced 
in the vessels within the cranium. If the emotion is very 
strong or lasting, a correspondingly-increased hyperemia re- 
sults. 

There are certain circumstances which render the action 
of the causes specified more effectual or powerful. These are 
inherent in the individual, and may be classed as predispos- 
ing causes. Among them are sex, the disease being more 
common in males ; age, it being more frequently met with 
in middle-aged or old persons ; hypertrophy of the left ven- 
tricle of the heart, by which the flow of blood to the head is 
directly increased ; dilatation of the right ventricle, by which 
its power is diminished, and the return of blood from the 
head impeded; insufficiency of the auriculo - ventricular 
valves, or constriction at the auricular or ventricular orifices 
on the same side, by which a similar result is produced, and 
perhaps, though this point is by no means established, short- 
ness of the neck. 

Diagnosis. — Cerebral congestion may be confounded with 
cerebral haemorrhage, meningeal haemorrhage, embolism, 
thrombosis, softening, epilepsy, urinaemia, stomachal vertigo, 
and with the very opposite condition, cerebral anaemia. From 
each of these affections it is, however, distinguished by well- 
marked characteristics. 

The premonitory symptoms are not liable to be mistaken 
for cerebral haemorrhage, but this error may be made as re- 
gards the second stage. The apoplectic form is, however, 
distinguished from apoplexy due to extravasation, by the 
fact that in it the loss of intelligence is rarely complete, 
and that, when it is so, the mind is dormant but for a few 
moments ; that sensibility and the power of motion are never 
altogether abolished; that coma, when present, is rarely 
profound; that the paralysis, when it exists, is seldom 



CEREBRAL CONGESTION. 47 

limited to one side of the body ; by the general absence of 
stertor, and pnffing of the lips and cheeks in breathing; 
and by the short duration of the symptoms. 

From meningeal haemorrhage it is discriminated by the 
comparative lightness of the symptoms, and by the fact that 
they do not progressively augment in severity or intermit in 
violence. 

Cerebral congestion and embolism present some features 
in common, and it is therefore occasionally difficult to dis- 
tinguish them. In the former, however, the pulse is slow 
and the respiration regular and deep, in the latter the pulse 
is more rapid, is often irregular, as is also the respiration ; 
in the former there is increased heat of the head, in the lat- 
ter the temperature of this part of the body is unchanged ; 
in cerebral congestion the symptoms are transient, in embo- 
lism they are more lasting ; in the former there is often a 
distinct premonitory stage, in the latter the attack always 
takes place without a moment's warning. In the former, 
though there may be cardiac difficulties, they are different 
from those predisposing to embolism, which are consecutive 
to endo-carditis — generally rheumatic — and which implicate 
the semi-lunar or mitral valves, and in the fact that recovery 
from an attack of cerebral congestion is generally complete, 
which is rarely the case in embolism. 

From thrombosis cerebral congestion is diagnosticated by 
the circumstances that in the former the progress of the dis- 
ease is slow, that there is usually well-marked paralysis from 
the beginning, that the phenomena indicating mental diffi- 
culty are more strongly pronounced, that the articulation 
and memory for words are more decidedly affected, and, not- 
withstanding occasional remissions, by the persistency and 
gradual advance of the symptoms. 

In softening there is often a sudden loss of consciousness, 
persistent hemiplegia, and death in a few days. Again, there 
is delirium without paralysis or convulsions, and again there 
is a gradual accession of the symptoms. This latter is the 



48 DISEASES OF THE BRAIN. 

only form liable to be mistaken for cerebral congestion. It is 
attended with headache, feebleness of intellect, and a gradu- 
ally-advancing paralysis generally, beginning in one of the 
lower extremities, and extending to the whole of one side of 
the body. The speech is always seriously impaired, and the 
mental disorder is of a far graver character than that due to 
cerebral congestion. The gradual advance of the affection 
to a fatal termination is also a characteristic circumstance. 

With urinsemia cerebral congestion may be confounded, 
if only the more obvious head symptoms be taken into con- 
sideration. The history of the case and full inquiry will 
always, however, enable the proper discrimination to be 
made. Thus in urinsemia the existence of kidney-disease as 
evidencd by a chemical and microscopical examination of the 
urine, the anasarca of the face or limbs, and the repeated at- 
tacks of convulsions and coma, will be sufficient diagnostic 
marks. 

From epilepsy cerebral congestion is distinguished by the 
fact that the former is not preceded by the group of symptoms 
constituting the first stage of congestion, that the period of 
greatest congestion of the vessels of the face and neck is at 
the beginning of the attack, that an aura is often present, that 
there may be a peculiar cry, that the patient does not stag- 
ger and fall slowly to the ground, but drops as if knocked 
down by a severe blow, and that the tongue is frequently 
bitten. The reverse is the case as regards all these phenomena 
in cerebral congestion. Nevertheless so accurate and expe- 
rienced an observer as Trousseau, in his clinical lecture on 
Apoplectiform Cerebral Congestion in its Relations to Epi- 
lepsy and Eclampsia* confounds the two conditions. Trous- 
seau's views on this subject do not, however, appear to be 
accepted by any large number of medical authorities. Epi- 
leptic vertigo is, as will be shown at the proper place, a very 
different affection from any form of cerebral congestion, and 

1 Clinique Medicale. Tome ii., p. 56. Also Bazire's Translation. London, 
1866, p. 19. 



CEREBRAL CONGESTION. 49 

is not likely to be confounded with it. Epileptic mania has, 
likewise, very few points in common with the disease under 
consideration. 

In stomachal vertigo the attacks of dizziness are often 
severe, but they are clearly associated with gastric derange- 
ment, and only occur while the stomach is digesting its con- 
tents. Other symptoms of dyspepsia will also be noticed, 
while the mental and physical disturbances which constitute 
so prominent a feature of cerebral congestion are absent. 
The distinction, however, is not always made. 

From cerebral anaemia the first stage of congestion is fre- 
quently not clearly distinguished, and I have seen several 
cases in which patients had been treated for the one condi- 
tion when the other was indubitably present. In both there 
are headache, sense of constriction, vertigo, noises in the ears, 
numbness, mental confusion, loss of memory, inaptitude for 
labor of any kind, and at times loss of consciousness. But 
in anaemia the face is not flushed, the carotid and temporal 
arteries do not throb with violence, the pulse is quick, feeble, 
and irregular, the respiration is hurried, the pupils are dilated, 
there are bellows murmurs at the base of the heart and in the 
veins of the neck, and the general aspect of the patient is not of 
that rugged appearance so generally associated with cerebral 
congestion. In the syncope of cerebral anaemia the paleness 
of the face, coldness of the skin, and feebleness of the heart's 
action, will serve to draw the line between it and the apo- 
plectic form of congestion. The ophthalmoscope will at all 
stages prove of great value in the diagnosis. 

Prognosis. — The prognosis is materially modified, accord- 
ing to the stage of the disease present when the patient is 
seen, and the form of attack from which he may be suf- 
fering. Active cerebral congestion is a more favorable type 
than the passive. If the affection has not gone beyond the 
first stage, a fortunate issue may safely be predicted under 
the use of suitable medical treatment. Of the six hundred 
and twenty-two cases under my care, but sixty passed to the 
4 



50 DISEASES OF THE BRAIN. 

second stage, and several of these had already suffered from 
previous seizures ; no death took place in any patient dur- 
ing the premonitory stage. The apoplectic form is the 
most grave, and the prognosis is rendered more unfavorable 
with each attack. The epileptic form is ordinarily not 
dangerous to life, nor is the maniacal, except in old persons. 
Occasionally, however, even in young and robust patients, 
death ensues during the paroxysms of these forms. 

The liability to secondary lesions, such as softening, cere- 
britis, haemorrhage, aneurisms, general paralysis, etc., must 
be taken into account when forming a prognosis. The 
more frequent the paroxysms of any form, the greater the 
risk of some such finality. 

The habits of the patient are also important elements in 
forming an opinion in regard to the ultimate result. If 
these are bad, and are persisted in, the probability is that no 
treatment will be of much avail in preventing a recurrence. 
Moreover, by such a condition of the brain as the excessive 
use of alcohol, inordinate mental exertion, or continual emo- 
tional excitement induce, the chance of escaping some sec- 
ondary morbid process is very much lessened. 

Of the sixty fully-developed cases which have been under 
my observation during the past five years, there were twelve 
deaths ; four from the apoplectic form, all after repeated at- 
tacks ; three from the maniacal, one of which was that of a 
young man, about thirty years of age ; and five from sec- 
ondary lesions. Of these latter, two were from softening, 
one from cerebritis, one from haemorrhage, and one from 
general paralysis. 

Morbid Anatomy. — There are certain appearances seen in 
the brains of those who have died of cerebral congestion 
which are characteristic, although it must be confessed that 
some or all of them are occasionally absent. These are : 

An increased size of the capillaries and large blood-vessels, 
both of the brain and the pia mater. It thus happens that, 
when a section of the brain is made, the red points ordinari- 



CEREBRAL CONGESTION. 51 

ly seen are larger and more numerous than usual, and that 
the pia mater presents in spots, or throughout its extent, a 
red or rose-colored appearance. 

The white matter of the brain is increased in density, 
and the gray matter is red, or even violet in hue. 

There is sometimes a large quantity of subarachnoiclean 
effusion, and the ventricles may contain an excessive amount 
of fluid. 

If there have been repeated attacks of cerebral conges- 
tion, it is not unusual to find, by microscopical examination, 
little granules of hsematin in contact with the blood-vessels. 
The same means of exploration show the minuter capillaries 
to be more than naturally tortuous, and to have little aneu- 
rismal swellings. These may or may not involve the whole 
circumference of the vessel. Their presence and import 
were first pointed out by Laborde. 1 

On making a transverse section of the hemisphere, a crib- 
riform appearance is seen, if the patient has repeatedly suf- 
fered from attacks of cerebral congestion, and especially if 
he be advanced in years. This is due to the presence of 
numerous little holes with sharply-defined margins. The 
brain-tissue bounding these is generally without material 
change, either in color or consistence. This condition, called 
by Durand-Fardel, to whom the credit of first describing it 
is usually given, u l'etat crible," 8 is supposed to be due to 
the fact that the vessels have been so distended during life 
as to press with increased force upon the perivascular tis- 
sue, and that, shrinking after death, they no longer fill their 
former space, which remains empty. Calmeil 3 was the 
first to notice this condition. He has very often found in 
maniacs the white substance, rendered cribriform by vessels 
distended with blood, sometimes empty, but always greatly 

1 La Ramollissement et Congestion du Cerveau principalement considered 
chez de Vieillard. Paris, 1866. 

2 Traite Pratique des Maladies des Vieillards. Paris, 1854. 

3 De la Paralysie considered chez les Alienes, etc. Paris, 1826. 



52 DISEASES OF THE BRAIK 

dilated. This state, although frequently met with in con- 
gestion, is not uncommon in other pathological conditions, 
such as the several forms of softening, of which, however, 
congestion is often the first stage. 

Pathology. — It is almost useless at this day to discuss the 
question of the possibility of the quantity of blood in the 
brain being subject to variation. Still it may be interesting 
to recall briefly the facts which establish the affirmative in 
the matter. 

In the cases of infants in whom the interior fontanelle is 
still open, the scalp is seen to be elevated above the level of 
the skull when the head is dependent, and depressed when 
the head is elevated. 

The same fact is observed in persons who have suffered 
injury of the skull, involving the loss of a portion of its sub- 
stance. During strong emotional excitement, or the action 
of any cause capable of increasing the force of the circula- 
tion, the scalp is elevated. From the action of opposite 
causes it is depressed. Both in infants and in persons who 
have received injuries such as those cited, the scalp is seen 
to be depressed during sleep, and to rise as soon as the indi- 
vidual awakes. 

A dependent position of the head causes a sensation of 
fulness, or even pain, and blood may flow from the nostrils. 
The eyes are observed to be " bloodshot," and the counte- 
nance indicates congestion. A tumor, a ligature, or any 
other cause capable of exerting pressure on the jugular veins, 
will produce like effects. Ophthalmoscopic examination 
under such circumstances shows the veins of the retina to be 
enlarged, indicating that an obstruction exists to the return 
of blood through the sinuses and veins within the cranium. 
Post-mortem examination of persons dying, who, during life, 
have suffered interruption to the perfect return of blood from 
the head, reveals the existence of intracranial congestion. 
Animals subjected to experiments calculated to act in the 
manner stated, are after death found to have congested brains. 



CEREBRAL CONGESTION. 53 

In animals bled to death the brain is found anaemic to 
an extreme degree. 

Direct experiment still more positively establishes the 
fact under consideration. If a portion of the skull of an 
animal be removed, and the aperture be then securely closed 
with a watch-glass, the vessels will be seen to enlarge and 
contract according to the cause brought into action, and the 
brain will be correspondingly elevated or depressed. 

By means of an instrument, devised, independently of 
each other, by Dr. S. Weir Mitchell and myself, the degree of 
pressure within the cranium can be accurately measured. It 
is thus seen that the quantity of blood circulating in the brain 
undergoes material variation. 1 

The anatomical arrangement of the blood-vessels of the 
cerebral tissue is such as to admit of an enlargement of their 
calibre without necessarily subjecting the perivascular sub- 
stance to pressure. Robin 3 discovered the existence of 
sheaths around these vessels, and his observations were sub- 
sequently confirmed by His, 3 who ascertained that the same 
arrangement exists in the spinal cord. According to His, 
" Fine transverse sections of a hardened brain, having its 
vessels injected or otherwise, show that all the blood-vessels, 
arteries, veins, and even capillaries, are surrounded by a 
clear space, broadest in the case of the larger vessels, but in 
all cases quite sharply defined externally. In transverse 
sections the vessels are seen to be surrounded by a ring-like 
space, and in parallel sections the space is seen on each side 
of the trunk of the vessel, and follows it in all its ramifica- 
tions." 

1 For a more complete argument on the subject, and for a statement in de- 
tail of the experiments of Mr. Durham and myself on this point, the reader is 
referred to the author's monograph, " Sleep and its Derangements." Philadel- 
phia: J. B. Lippincott & Co., 1870. The cephalo-hgemometer referred to in the 
text is described in that work (Appendix), and also in the introduction to this 
treatise. 

2 Journal de la Physiologie de l'Homme et des Animaux, 1859, p. 527. 

3 "Zeitschrift fur Wissenschaftliche Zoologie," 1865, B. xv., quoted in the 
Journal of Anatomy and Physiology. Translation by Dr. Bastian. 



54 DISEASES OF THE BRAIN. 

These perivascular canals are lined by a hyaline mem- 
brane, and are capable of being injected, and, in cases of 
chronic congestion, may become permanently enlarged, so as 
to cause the appearance referred to under the heading of 
morbid anatomy. 

The pathology of the subject receives further elucidation 
from a consideration of the causes capable of giving rise to 
cerebral congestion, and which have been already mentioned 
in detail. 

Treatment. — Recollecting the two grand forms of cere- 
bral congestion, the principles which should guide us in 
treatment will be clearly apparent. In the active type of 
the disease the force of the cerebral circulation and the 
quantity of blood in the blood-vessels of the brain are to be 
lessened ; in the passive variety the force of the circulation 
is to be increased, and at the same time the accumulation of 
blood in the veins to be diminished. In the active form of 
this affection the abstraction of blood from the arm was for- 
merly very generally practised, but is now rarely performed. 
I have never seen a case in which it was required. Local 
bleeding is more generally applicable, and a few cups to the 
nape of the neck will often afford marked relief. Leeches 
to the temples are also useful, though they are preferably 
applied just inside the nostrils. I have many times wit- 
nessed the most satisfactory results from a couple of leeches 
thus used, and from accidental nasal haemorrhage. 

Cold is another very useful agent in the treatment. It 
may be applied to the nape of the neck, or directly to the 
cranium, either as very cold water or in the form of ice. 

The advantages of position should also be brought to 
bear. The head should be kept elevated, especially during 
sleep, and no severe muscular exertion should be taken while 
stooping. 

The clothing should be kept loose about the neck. As 
derivatives, a mustard-plaster applied to the epigastrium is 
often of service, and the same may be said of warm or even 



CEREBRAL CONGESTION. 55 

hot water to the feet. Blisters I rarely employ, though 1 
have occasionally done so with advantage. 

The constant galvanic current possesses the power of con- 
tracting the cerebral blood-vessels, when so used as to stimu- 
late the sympathetic nerve. For this purpose one pole, the 
positive, should be placed over this nerve in the neck ; and 
the other, the negative, on the neck, as low down as the sev- 
enth cervical vertebra. The current from about fifteen 
Smee's cells is sufficient, and it should not be allowed to 
act for more than two minutes. If extreme vertigo be pro- 
duced, the number of cells should be lessened. This prop- 
erty of the primary current was first pointed out by Ber- 
nard, "Waller, and Budge, but its demonstration by the oph- 
thalmoscope was first made by myself. 1 Observation with 
this instrument, while the current is acting, shows that the 
vessels of the retina contract, and hence there can be no 
doubt that the result is produced upon those of the brain. 
A similar effect is caused by passing the current directly 
through the brain, the poles being applied to the mastoid 
processes. A slight feeling of vertigo follows both when 
the circuit is closed and opened. The good effects of this 
practice are well marked, a few applications being often 
sufficient to abolish the vertigo and unpleasant feelings in 
the head, and to restore mental and physical activity. 

Of internal remedies the number is not large, and those 
which it is advisable to employ are generally effectual, with 
or without the external measures mentioned, in entirely re- 
lieving the patient. 

First among these must be placed the bromide of potas- 
sium. Over five years ago I pointed out the value of this 

1 See a memoir entitled " Spinal Irritation," read before the Medical Society 
of the County of New York, January 17, 1870, and published in the Journal of 
Psychological Medicine for April of the same year. Also another, " On some of 
the Effects of Excessive Intellectual Exertion," in the Bellevue and Charity Hospi- 
tal Reports for 1870. In both these papers, and in my lectures to the class of 
the Bellevue Hospital Medical College, I have made distinct mention of this 
fact. 



56 DISEASES OF THE BRAIN. 

medicine, and explained the rationale of its action. As 
others have since claimed the discovery as their own, I hope 
I may be excused for quoting the following passage from a 
memoir upon an analogous subject, 1 in which the action of 
the bromide is clearly indicated : 

" Bromide of potassium can almost always be used with 
advantage to diminish the amount of blood in the brain, 
and to allay any excitement of the nervous system that may 
be present in the sthenic form of insomnia. That the first- 
named of these effects follows its use, I have recently ascer- 
tained by experiments upon living animals, the details of 
which will be given hereafter. Suffice it now to say that I 
have administered it to dogs whose brains have been ex- 
posed to view by trephining the skull, and that I have inva- 
riably found it to lessen the quantity of blood circulating 
within the cranium, and to produce a shrinking of the brain 
from this cause. Moreover, we have only to observe its effects 
upon the human subject, to be convinced that this is one of 
the most important results of its employment. The flushed 
face, the throbbing of the carotids and temporals, the suffu- 
sion of the eyes, the feeling of fulness in the head, all dis- 
appear as if by magic under its use. It may be given in 
doses of from ten to thirty grains, the latter quantity being 
seldom required, but may be taken with perfect safety in 
severe cases." 

Since then, experiments with the cephalo-hsemometer and 
ophthalmoscope have abundantly confirmed these views, and 
more extensive experience in the treatment of cerebral con- 
gestion has placed the matter beyond the possibility of a 
doubt. Other observers have also confirmed the opinions 
here expressed. 

The prescription which I usually employ consists of bro- 
mide of potassium, gj ; water, %iy; of this a teaspoonful is 
taken three times a day in a little water. Occasionally the 

1 On Sleep and Insomnia. New York Medical Journal, June, 1865, p. 
203. 



CEREBRAL CONGESTION. 57 

bromide is increased to 5 iss, and sometimes a saturated so- 
lution — which contains grs. xxx to 3 j — is used. I continue 
the medicine till drowsiness, a slight feeling of weakness in 
the legs, and contraction of the blood-vessels of the retina — 
detected by the ophthalmoscope — are produced. The more 
prominent head-symptoms generally disappear in four or five 
days, and the results above-mentioned ensue in about ten days. 

Latterly I have used the bromide of sodium in corre- 
sponding doses instead of the bromide of potassium. It is 
more pleasant to the taste, and does not cause so much con- 
stitutional disturbance as sometimes follows the administra- 
tion of the bromide of potassium in large doses. 

In conjunction with one or other of the bromides men- 
tioned, I very generally employ the oxide of zinc, which 
experience has taught me is a powerful agent in relieving 
cerebral congestion, and giving tone to the nervous system. 
It should be given in doses of grs. ij, three times a day, 
either in the form of a pill or powder, and to avoid any nau- 
sea should be taken after meals. At the end of about ten 
days it will generally be found that all symptoms of conges- 
tion — subjective and objective — have disappeared, leaving 
a little debility and mental depression. It then becomes 
expedient to give tonics and restoratives, and those which 
have a special action on the nervous system are to be pre- 
ferred. Among them, strychnia, phosphorus, and cod-liver 
oil, stand first. 

Strychnia may be advantageously administered in con- 
junction with iron and quinine dissolved in dilute phosphoric 
acid, as in the following formula : strychnise sul. gr. j ; ferri 
pyrophosphatis, quinige sul., aa, 3 j ; acid, phosp. dil., zingi- 
beris syrupus, aa, 5 ij- ^- ft- mist. Dose, a teaspoonful 
three times a day in a little water. I prefer this extempo- 
raneous prescription to any of the syrups or elixirs with like 
ingredients. If for any reason the iron and quinine are not 
indicated, the strychnia can be given alone with the dilute 
phosphoric acid. 



58 DISEASES OF THE BRAIN. 

Phosphorus almost always acts well in such cases as those 
under consideration. It may be given in the form of the 
phosphorated oil, as in the following formula : ^ • Olei phos- 
phorat., §ss; mucil. acacise, 5j> °l e i bergamii, gtts. xl. 
M. ft. emulsion. Dose, gtts. xv three times a day. A very 
elegant preparation of phosphorus is the phosphide of 
zinc, which was imported at my request about two years 
ago, by Mr. Neergaard, the eminent pharmaceutist of this 
city, and which I was certainly the first to use in this coun- 
try. M. Moutard Martin, M. Dujardin-Beaumetz, my friend 
M. Gueneau de Mussy, and other Parisian physicians, had 
previously employed it. My experience with this medicine 
has been very extensive. I have never known it to pro- 
duce the least unpleasant effect, and have rarely been disap- 
pointed in obtaining the full results to be expected from 
phosphorus in corresponding doses. I am, therefore, not in 
accord with Dr. M. Clymer * on this point. 

The chemical formula of the phosphide of zinc is P. 
Z n3 , and consequently a grain represents a little more than 
one-seventh of a grain of phosphorus. The proper dose, 
therefore, is about the tenth of a grain. I usually prescribe 
it in cerebral congestion, according to the following prescrip- 
tion: 9- Zinci phosphidi, grs. iij ; rosar. conserv., q. s. M. 
ft. in pill, No. xxx. Dose, one three times a day. Instead 
of the conserve of roses, grs. x of the extract of nux- vomica 
may be substituted if strychnia is not being administered in 
some other form. 

Such is the treatment I have found to be most advanta- 
geous in active cerebral congestion, and I rarely have occa- 
sion to supplement it with other measures, unless some special 
indication is to be fulfilled. Thus, if the bowels are consti- 
pated, a mild purgative may be given, or preferably an enema 
of warm water or olive-oil ; or, if the urine is scanty and 
high colored, saline diuretics are useful. 

In the passive form of the disease it is sometimes advis- 

1 New York Medical Journal, vol. x., 1870, p. 476. 



CEREBRAL CONGESTION. 59 

able to give stimulants, which may be done from the first in 
conjunction with the bromide of potassium or sodium. Al- 
cohol in some form is to be preferred when it is well borne, 
though carborate of ammonia is sometimes a useful substitute. 
In several cases of passive cerebral congestion in old people, 
and in one notable instance occurring in the person of a very 
prominent, elderly gentleman of this city, I derived the 
most satisfactory results from sulphuric ether inhaled from a 
handkerchief to the extent of a teaspoonful, several times a 
day. The pain, constriction, vertigo, numbness, wakeful- 
ness, and inability to exert the mind, were lessened with 
every dose, and finally entirely disappeared. Ether may 
likewise be given by the stomach — gtts. xv several times 
daily — in case the inhalation is contraindicated from any 
cause. 

Of course, any influence capable of interfering with the 
due return of blood from the head should be counteracted at 
once. 

Hygienic treatment should in both types of the disease be 
persistently carried out. The food should be nutritious, diges- 
tible, and ample, though not excessive, in quantity. Alcohol 
and tobacco, if used habitually by the patient, should be re- 
stricted to moderate limits ; I have never seen the latter do 
harm unless used to excess. Tea and coffee may safely be left 
to the patient's own inclinations and experience. I believe 
more harm is done by suddenly breaking off a habit even 
though it be somewhat injurious, than by tolerating it within 
due bounds. Exercise in the open air — walking, horseback- 
riding, or driving — is always beneficial. The same cannot be 
said of gymnastic contortions, which, to make them worse, 
are usually performed in hot rooms. Bathing daily and sub- 
sequent friction with a tape towel are exceedingly useful in 
determining blood to the surface of the body. The Turkish 
bath cannot be too highly commended. 

But, above all, those persons who have brought on the dis- 
order by inordinate mental exertion or anxiety must con- 



60 DISEASES OF THE BRAIN. 

sent to use their brains in a rational manner if they wish to 
recover or to avoid future attacks. They have received a 
warning, and, if they do not heed it, sooner or later other 
diseases, more difficult if not impossible of cure, will make 
their appearance. 

The cause, whatever it be, must, if practicable, be re- 
moved, and it must continue removed. 



CHAPTEK II. 

CEBEBBAL ANAEMIA. 

In cerebral anaemia the quantity of blood in the brain is 
either reduced below the normal standard, or the quality 
of the circulating fluid is impoverished. The first-named 
condition is due either to direct loss of blood, to deficient ac- 
tion of the heart, to impaired nutrition, or to some cause pre- 
venting the due access of blood to the brain ; the second to 
disease of some organ concerned in haematosis or to a general 
cachexia. 

The two states very often coexist, and they may properly 
be considered together. 

Symptoms. — In cerebral anaemia, suddenly induced from 
profuse haemorrhage, the most prominent symptom is syn- 
cope. Yertigo is generally an attendant, and there are pale- 
ness of the features and coldness of the extremities. The 
pulse is frequent, thread-like, and weak. The respiration 
feeble and accelerated. 

But, when the accession is more gradual, headache is very 
generally present. It may be, and usually is, confined to a 
limited portion of the head, sometimes to a spot not larger 
than the point of the finger. A feeling of constriction, es- 
pecially across the brows, is complained of, and the vertigo, 
notably increased on rising from the recumbent posture, is as 
troublesome a feature as in the worst attacks of cerebral con- 
gestion. There is ringing in the ears, and loud noises are 
not only painful but are exceedingly irritating to the ner- 
vous system. The pupils are largely dilated, and are slug- 



62 DISEASES OF THE BRAIN. 

gish, contracting slowly and but little on exposure to a strong 
light. These phenomena may be restricted to one eye, a cir- 
cumstance which generally occasions needless alarm on 
the part of the patient. The retinae are extremely sensitive, 
and hence ophthalmoscopic examination is painful. When 
employed, the vessels at the fundus of the eye are seen to be 
small and straight, and the choroid is paler than is normal. 

The complexion is pale, the lips almost colorless, or else 
redder than in health. The skin is cold and clammy. 

Nausea and vomiting are present in extreme cases, and 
convulsions of an epileptic character may occur. In the 
rapidly-developed form of the disease caused by sudden and 
great loss of blood they are always present, and in the milder 
and more gradual variety they are occasionally seen. Fee- 
bleness of muscular power is always met with, and there 
may be general or partial paralysis with the usual derange- 
ments of sensibility indicative of anaesthesia, such as coldness, 
formication, and " pins and needles." 

The mind, of course, participates in the general disorder. 
In extreme cases, due to active haemorrhage, the patient is 
completely insensible. In less severe forms there may be 
all the gradations from low delirium to great mental irrita- 
bility, or a condition of intellectual lassitude approaching 
dementia. 

Hallucinations and illusions are common in the slowly- 
developed forms of cerebral anaemia, and may affect any one 
or all of the senses. Those of sight and hearing are, how- 
ever, more prominent. In the case of a young lady now 
under my care, and whose only marked disorder is that un- 
der consideration, the hallucination that she sees a black man 
is almost constantly present. At times she converses with 
this imaginary being, tells him not to trouble her, that she 
no longers fear him, etc. She believes firmly in his presence, 
and hence has a delusion. 

In all cases of cerebral anaemia there is more or less 
drowsiness, from the profound syncope of the rapid form to the 



CEREBRAL ANAEMIA. 63 

rather agreeable languor present in slight cases. In instances 
of medium severity the patient readily falls asleep in the sit- 
ting posture, but recumbency induces wakefulness from the 
fact that the quantity of blood in the brain is thereby sud- 
denly increased above the habitual standard, and a state of 
comparative hyperaemia is thus induced. I have, in another 
place, 1 called attention to this form of insomnia, and adduced 
several cases in illustration. 

Examination of the heart by auscultation reveals the ex- 
istence of bellows murmurs both systolic and diastolic. They 
are heard more loudly at the base of the heart. There are 
also very generally venous murmurs which are heard most 
distinctly in the jugular veins, especially when the head is 
turned toward the opposite side. Arterial murmurs may 
also occasionally be perceived. 

These sounds are sometimes heard by the patient, and are 
then exceedingly annoying. I have now under my charge a 
gentleman suffering from cerebral anaemia, who constantly 
hears a sound originating apparently in the head, and which, 
as he describes it, resembles that caused by a large shell 
placed to the ear. That these murmurs are anaemic is shown 
by the fact that they disappear under appropriate treat- 
ment. 

A form of cerebral anaemia met with in young children 
is of great importance, from the fact of its liability to be con- 
founded with another far more dangerous affection, almost 
its opposite. This was first clearly described by Dr. Gooch, 3 
although previously noticed by other observers. In children 
suffering from this affection, the symptoms, so far as they 
are noticeable, are similar to those present in the anaemia of 
adults. The drowsiness is well marked, the head is cool, the 
pulse is small and weak, the features are pinched, the pupils 
large and insensible to light, and the fontanelle, if still open, 

1 "Sleep and its Derangements." 

8 On Some of the most Important Diseases peculiar to Women ; with Other 
Papers. New Sydenham Society Publication. London, 1859, pp. 179. 



64 DISEASES OF THE BRAIN. 

has the scalp covering it depressed. After death, the vessels 
of the brain are found to be almost empty, and the ventricles 
distended with fluid. From its resemblance in some respects 
to hydrocephalus or tubercular meningitis, this affection was 
called by Dr. Marshall Hall hydrocephaloid. The distinc- 
tion, however, is so well defined that none but the most ig- 
norant or superficial observers would fail to recognize it. 

Causes. — Haemorrhage or other exhausting discharge ranks 
first among the causes of cerebral anaemia. I have known 
several severe cases induced by epistaxis, and one by the con- 
tinued loss of blood from leech-bites. Hemorrhoidal bleed- 
ing has also caused it in my experience. No influence of the 
kind is, however, more common than uterine bleeding, such 
as occurs before, during, or after labor, from miscarriages 
and abortions, especially if they are frequently repeated, and 
from excessive menstrual discharge. 

Chronic dysentery and diarrhoea, malarial and other fe- 
vers, the rheumatic, strumous, and cancerous diatheses, dis- 
eases of the bones and joints, and long-continued purulent 
discharges, are likewise causes of cerebral anaemia. 

I have several times seen the affection apparently caused 
by congestion of internal organs. Niemeyer, referring to 
this possibility, cites the fact that it may follow the use of 
Jounod's boot. At the present time, when this appliance is 
variously modified and extended beyond its legitimate use 
by itinerant quacks, it is well to call special attention to this 
liability. Several cases in point have come under my obser- 
vation, and in one, a young lady suffering from epilepsy with 
cerebral anaemia, whom I saw in consultation with my friend 
Dr. J. Marion Sims, severe paroxysms were induced by each 
application of the " exhauster." In this case the operator 
placed the whole body, with the exception of the head, in a 
vacuum. In another instance exhaustion from the leg alone 
caused syncope every time the operation was performed. 

Pressure or obliteration upon the arteries supplying the 
brain is another cause. A lady was recently under my no- 



CEREBRAL ANEMIA. (55 

tice in whom both carotid arteries had been tied, for cirsoid 
aneurism of the scalp, by the late Dr. Kearney Eodgers and 
my friend Prof. "W. H. Yan Buren. "When I saw her, sev- 
eral years after the operation, there was well-marked cere- 
bral anaeinia, the most striking symptoms of which were 
vertigo and drowsiness. Tumors of various kinds may act 
in a similar manner. Feebleness of the heart's action, such 
as results from fatty degeneration, may also occasion cerebral 
anaemia. 

As we have seen, excessive mental exertion is a common 
cause of cerebral congestion. Strange as it may appear, I have 
had several cases of cerebral anaemia under my care in which 
the disease was clearly the result of a like cause, and these 
were instances in which the brain had been overtasked to an 
extreme degree. A little reflection will, I think, show that 
such cases are strictly in accordance with what takes place 
in other parts of the body. Thus we see the moderate use 
of a muscle or set of muscles increase their size and strength. 
Inordinate exercise induces hypertrophy, but, if the power 
of the muscles be still more severely tried, atrophy results. 
One of the worst cases of progressive muscular atrophy I ever 
saw occurred in the person of a ballet-dancer, whose gastro- 
cnemii muscles were the apparent starting-points of the dis- 
ease. Excessive cerebral action produces exhaustion and 
exhaustion causes anaemia, as surely as anaemia causes ex- 
haustion. 

The action of mental emotions is more obvious. "We 
know that some emotions increase the amount of blood in 
the brain. Others diminish it, and sometimes with such sud- 
denness as to cause syncope. Fear is one of these, and we 
have all seen the face become pale under its influence. 

Certain medicines are causes of cerebral anaemia, both by 
their action on the vaso-motor nerves and in diminishing 
the power of the heart. Tobacco, tartarized antimony, 
calomel, oxide of zinc, and the bromides of potassium, sodi- 
um, and lithium, are among the chief of these. I was the 
5 



66 DISEASES OF THE BRAIN. 

first to point out this influence of the bromides, and in a re- 
cently-published memoir 1 have given several cases in illustra- 
tion of its action. The drowsiness, vertigo, nausea, fainting, 
weakness of the muscular system, numbness, failure of mem- 
ory, mental aberration, pallor of the countenance, and anae- 
mia of the retina, all go to show that the quantity of blood 
in the brain is diminished. Recent investigations not yet 
published have convinced me that the oxide of zinc acts in 
a similar manner. 

Insufficient nutrition, either from deficient or improper 
food or disease of the digestive or assimilative organs, is a 
very common cause. Through its influence not only is the 
absolute amount of blood lessened, but its quality is deterio- 
rated. The quantity sent to the brain is hence diminished, 
and that which is supplied is lacking in its proper proportion 
of red corpuscles. Many of the cases of cerebral anaemia oc- 
curring in large cities originate from such influences, and 
likewise from the vitiated air of narrow and crowded streets, 
from cold and from deprivation of light. 

Diagnosis. — The principal affection with which cerebral 
anaemia is liable to be confounded is cerebral congestion. 
Indeed, there is no other which can be mistaken for it, if even 
ordinary perception and judgment be exercised. 

From this it may be diagnosticated by the history of the 
case, and a careful inquiry into the etiology, by the fact that 
drowsiness, not wakefulness, is a prominent symptom ; that 
the pupils are dilated instead of being contracted ; that the 
pain is more apt to be fixed in a limited part of the head 
instead of being general, that it and the vertigo are increased 
by the assumption of the erect position, and diminished by 
lying down ; that the ophthalmoscope shows retinal anaemia ; 

1 On Some of the Effects of the Bromide of Potassium when administered in 
Large Doses. Quarterly Journal of Psychological Medicine, January, 1869, 
p. 46. In this paper I stated that one of the most constant phenomena was 
contraction of the pupils. Very greatly increased experience has convinced me 
that this is an occasional circumstance, which occurs during the early period of 
administration only. 



CEREBRAL ANEMIA. 67 

that the face is pale and the skin cold ; that the pulse is weak 
and frequent, and that bellows murmurs are heard at the base 
of the heart and in the veins of the neck. The effect of 
stimulants and tonics in mitigating these symptoms, and the 
fact that they are increased by exertion, and debilitating in- 
fluences, are also important points to be considered in form- 
ing a diagnosis. Attentive consideration of these differen- 
tial phenomena will prevent a mistake which may be fatal to 
the patient. 

Prognosis. — The prospect of recovery in cases of cerebral 
anaemia depends mainly upon the removal of the cause, and 
the adoption of suitable treatment. In those cases which are 
the result of sudden and profuse loss of blood, the prognosis 
is grave, and this is especially so if the patient is pulseless 
and convulsions have occurred. In such instances, even 
though the haemorrhage has been arrested, it may be im- 
possible to save the patient. 

In the gradually-developed form the prognosis is gener- 
ally favorable. 

Morbid Anatomy. — The vessels of the brain and its mem- 
branes are observed upon post-mortem examination to con- 
tain less than the normal amount of blood. The tissue of 
the brain is pale, and section shows a diminished number of 
the red points in the white substance. Sometimes there is 
an increased amount of serous effusion in the subarachnoid 
space, but the ventricles are generally empty. 

Pathology. — The questions to be discussed under this head 
are similar to those connected with the same point in cere- 
bral congestion. That the quantity of blood within the cra- 
nium can be diminished as well as increased admits of no 
doubt, and the fact that the symptoms grouped together as 
indicating the existence of cerebral anaemia are really the 
result of deficient blood-supply to the brain is equally cer- 
tain. The experiments of Kussmaul and Tenner, 1 as well as 
those of other physiologists, are perfectly convincing. 

1 Untersuchungen iiber Ursprung und Wesen der fallsuchtartigen Zuckungen, 



68 DISEASES OF THE BRAIN. 

To observe in man the effects of even temporarily cutting 
off the supply of blood to the brain, it is only necessary to 
compress the carotid arteries for a few moments. I have 
repeatedly done this in rabbits to the extent of producing 
insensibility and convulsions. Jacobi 1 relates the following 
symptoms as generally observed in the human subject: Dim- 
ness of sight, dizziness, stupor, weakness in the legs, stagger- 
ing, swooning, loss of consciousness, and sudden apoplectic 
falling down. 

Dr. Alexander Fleming 8 tried the effect of compressing 
the carotid arteries. " There is felt a soft humming in the 
ears, a sense of tingling steals over the body, and in a few 
seconds complete unconsciousness and insensibility supervene 
and continue as long as the pressure is maintained. I have 
recently performed this experiment several times, with the 
effect of producing similar phenomena, together with pallor 
of the countenance, dilatation of the pupils, and temporary 
headache. 

In many cases of cerebral anaemia, the cause, as we have 
seen, resides in the blood-producing functions, and is such 
as to cause the formation of blood which does not contain its 
due supply of red corpuscles. Here, although there may be 
no diminution in the actual volume of this fluid circulating 
in the cerebral vessels, the effect is the same so far as the 
nutrition of the organ is concerned, and hence the symptoms 
of anaemia are slowly evolved. 

Again, it cannot be doubted that spasm of the blood- 
vessels produced through the sympathetic and vaso-motor 
nerves explains the origin and continuance of many cases of 
cerebral anaemia. It is in this way that mental emotions 

Frankfurt, 1857. Also, On the Nature and Origin of Epileptiform Convul- 
sions, caused by Profuse Bleeding, etc. New Sydenham Society Translation, 
1859. 

2 Quoted by Kussmaul and Tenner. 

1 British and Foreign Medico-Chirurgical Review, April, 1855, p. 529, in a 
paper entitled " Note on the Induction of Sleep and Anaesthesia by Compression 
of the Carotids." 



CEREBRAL ANEMIA. 69 

act, and sometimes with such rapidity as to cause instant 
death. This spasm may be kept up for a very considerable 
period, with the effect of developing the ordinary symptoms 
of cerebral anaemia, even after the emotion which originated 
it has long since disappeared. 

Treatment. — The first indication to be fulfilled in the 
treatment of cerebral anaemia is to get rid of the cause. It 
often happens that this is still in active operation when pa- 
tients come under our care, and there is no hope of perma- 
nent success till it is removed. Thus, if there is haemor- 
rhage from a divided vessel, from the uterus, the bowels, the 
lungs, or other part of the body, it must be arrested ; if there 
is exhausting discharge from the air-passages, the intestines 
or the genital organs, it must be stopped ; if the digestive or 
assimilative organs do not perfectly perform their offices, 
they must be put in good condition, if a tumor or other ob- 
struction to the due course of the blood to the brain exist, it 
must be removed ; and if the hygienic conditions surrounding 
the patient be bad, or the food inadequate in quantity or 
quality, they must be improved. 

No medicine exercises so powerful an effect in cerebral 
anaemia as alcohol in some form or other. Perhaps, all things 
considered, the spirituous liquors, such as whiskey, brandy, 
and rum, are more generally applicable. For the influence 
is more rapidly felt, and there is not the same risk of excit- 
ing or aggravating gastric disorder, as when vinous or malt 
liquors are used. The quantity must be regulated according 
to the circumstances of each case, and should always be large 
enough to materially increase the force of the heart. 

But if this were the only effect of alcohol, its benefits in 
cerebral anaemia would be but temporary, and would cer- 
tainly be followed by a period of depression. Aside, how- 
ever, from its stimulating action in the heart, its tendency is 
to improve the appetite and digestive power, and to relax 
any spasm of the blood-vessels that may be present. 

Occasionally it happens that alcohol is badly borne by 



70 DISEASES OF THE BRAIN. 

anaemic patients. The brain has for so long a time been de- 
prived of a due amount of its natural stimulus — blood — that 
time is required to enable it to tolerate and be improved in 
tone by the increased supply. Thus the physician will find 
that in some cases the patients will be apparently rendered 
worse by the remedy which of all others is calculated to do 
them most good. The headache and vertigo are increased, 
and the general feeling of debility and malaise greatly aug- 
mented, and the complaint made that the liquor has " gone 
to the head." 

Kow, it must be recollected that the brains of anaemic per- 
sons are in very much the same condition as the eyes of those 
who have for a long time been shut out from their natural 
stimulus — light. When the full blaze of day is allowed to fall 
upon their retinae, pain is produced, the pupils are contracted, 
and the lids close involuntarily. The light must be admitted 
in a diffused form, and gradually, till the eye becomes accus- 
tomed to the excitation. So it is with the use of alcohol in 
some cases of cerebral anaemia. The quantity must be small 
at first, and it must be administered in a highly-diluted form, 
though it may be frequently repeated. Cases in which this 
intolerance of stimulants is exhibited are almost invariably 
of long duration, and are as those in which from a like cause 
wakefulness is produced by the recumbent posture. 

The carbonate of ammonia, or the aromatic spirits of am- 
monia, may be given if there are any special reasons why alco- 
hol should not be used, but they are not to be compared to it 
in efficacy. 

In very extreme cases ether is preferable for the time 
being to any other remedy, on account of its diffusive na- 
ture ; and transfusion may be necessary to save life. 

As adjuncts to alcohol, the bitter tonics, such as quinine, 
gentian, Colombo, and quassia, are useful. Iron is almost 
always required, though there are patients who do not tol- 
erate it. In such cases manganese may be substituted with 
advantage. I have frequently used the sulphate, in doses of 



CEREBRAL ANJEMIA. 71 

five grains, with excellent results. When iron is borne, I 
know of no better combination than that given on page 57. 
Cod-liver oil is also a valuable agent in the disease under 
consideration. 

It must not be forgotten that food is the most important 
factor in relieving chronic cerebral anemia. The main per- 
manent influence of stimulants and tonics is exerted upon the 
appetite and digestion, and the blood and tissue forming func- 
tions mainly as an excitant. The real strength must come 
from the food. This should, therefore, be of good quality ; 
animal food, such as milk, eggs, and meats of various kinds, 
forming its chief portion. 

The influence of position should always be taken advan- 
tage of to facilitate the flow of blood to the head, and the 
erect posture avoided as far as possible, especially during 
the early stages of the treatment. Thus the patient should 
be encouraged to pass a good portion of the day in a recum- 
bent position, and should be instructed to assume it at once 
on the occurrence of any aggravation of the symptoms. 

The opposite course is fraught with danger. Physicians 
are often anxious that their patients should take physical 
exercise, but it must be recollected that those who suffer 
from cerebral anosmia have very little vital energy and a di- 
minished amount of blood circulating through the organ 
from which the greater part of their nervous power comes. 
Muscular exercise lessens the energy, and still farther re- 
duces the quantity of blood in the brain, for the muscles 
require an increased supply while in a state of activity. To 
be sure, after the strength of the system is in a measure im- 
proved, the blood increased in quantity and quality, and the 
brain supplied with something like its proper proportion, 
moderate physical exercise is of the greatest service. 

I have several times witnessed severe consequences from 
the assumption of the sitting or erect position too soon after 
a profuse haemorrhage, and in one case death resulted. 

As regards mental labor, there is not much need of cau- 



72 DISEASES OF THE BRAIN. 

tion, for the reason that it is impossible for the patient to 
undertake it to any dangerous extent. But, as he improves 
in strength, the desire to make use of his increased power 
may be manifested. It is, therefore, well at this time to 
prohibit any such exertion as will probably be followed by 
marked depression. Moderate mental exercise is, however, 
far from being prejudicial, for it tends to increase the amount 
of blood in the brain. 

Emotional disturbance should also, as a rule, be avoided, 
although at times it may be productive of great benefit, es- 
pecially if it be possible to bring into action an emotion con- 
trary to that which may have produced the disease. Thus 
a lady became subject to cerebral anaemia, directly the result 
of painful emotions due to domestic trouble. The difficulty 
was very suddenly removed, or rather the knowledge of its 
removal was suddenly communicated to her. The reaction 
was very great ; she was thrown into a state of joyous ex- 
citement, attended with considerable febrile disturbance, and 
I was apprehensive for a time that her mind might become 
permanently deranged, for there were hallucinations and de- 
lusions of various kinds, and many symptoms of cerebral con- 
gestion. But in the course of a few days, during which she 
was kept in entire seclusion, and as far as possible from all 
mental and physical agitation, she entirely recovered both 
from the secondary and primary disorders. 

One word in regard to what not to do. From what has 
already been said in this and the previous chapter, the reader 
will have perceived that it would be exceedingly injudicious 
to administer any of the bromides in the treatment of cere- 
bral anaemia. I should not, therefore, deem it necessary to 
say any thing further in regard to this point, but for the fact 
that I am very sure, from my experience, that wrong ideas 
prevail among some physicians relative to this subject. I 
see many patients affected with the disease under considera- 
tion, who have been treated with the bromide of potassium, 
and invariably with the effect of aggravating the difficulty. 



CEREBRAL ANEMIA. 73 

Care in making a diagnosis and a knowledge of the fact 
that the bromides lessen the amount of blood in the brain 
are points which it is necessary to insist npon, even at the 
risk of being tiresome by repeating what has already been 
said. 



CHAPTEK III. 

CEREBRAL HEMORRHAGE. 

Under the designation of cerebral haemorrhage I propose 
to consider that disease which is often known as apoplexy, 
hemiplegia, or a paralytic stroke, and which is due to the 
rupture of a blood-vessel, and the consequent extravasation 
of blood either into the substance of the brain or into its 
ventricles. 

Two forms of the affection, differing essentially only in 
the extent or seat of the lesion, but presenting different symp- 
toms, are to be distinguished ; these are the apoplectic and 
paralytic. In the first there is loss of consciousness ; in the 
second the mind, though perhaps impaired, is not suspended 
in its action. 

Symptoms. — Before the full development of the attack 
there often is, for several days, a group of symptoms present 
which indicate cerebral disorder. These are very much of 
the same character as those denoting the first stage of cere- 
bral congestion, but, though generally not so numerous, are 
far more striking. 

Among the more obvious is a sudden difficulty of speech 
arising from slight paralysis of the tongue and other muscles 
concerned in articulation. Words are not pronounced with 
the usual distinctness; the tongue seems to occupy more 
space in the mouth than it should, and is not moved with 
the requisite degree of promptness and rapidity. 

The other muscles on one side of the face may be affected, 
and hence there is a little distortion, lasting, perhaps, but 
for a few hours. 



CEREBRAL HEMORRHAGE. 75 

Defects of sight may occur, usually characterized by the 
presence of dark spots in the axis of vision. Such difficul- 
ties are due to minute extravasations in the retinae, and are 
always of most serious importance. I have known retinal 
clots to precede by more than a year the occurrence of a 
more severe lesion. 

Bleeding from the nose is a common precursor, and when 
occurring without being increased by severe muscular exer- 
tion, blows, a dependent position of the head, or other obvi- 
ous cause in a person over the age of forty, is always to be 
regarded as a symptom of moment. 

Numbness limited to one side of the body is of itself suf- 
ficient to excite apprehension. I have known several cases 
in which this symptom was the only premonitory sign. It 
may be present several days before, or may precede the at- 
tack by only a few minutes. 

In addition, there may be headache, vertigo, slight con- 
fusion of mind, a tendency to stupor, and vomiting. 

None of the premonitory symptoms may be present, and 
then the attack, if of the apoplectic form, occurs with great 
suddenness. Even if they have been noticed, there is more 
or less of abruptness in the onset. 

Thus the individual is perhaps standing engaged in con- 
versation, when he is instantaneously struck with uncon- 
sciousness, and falls to the ground as if shot ; sensibility and 
the power of motion are abolished, and no signs of vitality 
are apparent to the ordinary observer, with the exception 
of the slow and labored action of the heart and respiratory 
muscles. The breathing is stertorous, the lips and cheeks 
are puffed out with each expiration, and the pupils are gen- 
erally largely dilated and insensible to light. 

Keflex movements are abolished at first, but after a few 
moments they reappear, and are even more readily excited 
than in health, owing to the fact that the controlling influ- 
ence of the brain is removed. 

The voluntary power of swallowing is lost, but it is usu- 



76 DISEASES OF THE BRAIN. 

ally not difficult to cause contraction of the muscles of deg- 
lutition by excitation of the pharynx. "When these cannot 
be produced, the prognosis is, if possible, increased in grav- 
ity, for the reason that the extravasation is probably in the 
medulla oblongata, or so situated as to compress it. 

The urine and fasces are often evacuated involuntarily. 

An apoplectic attack of this character usually terminates 
in death without the patient recovering his intellect in the 
slightest degree. If life should be prolonged for thirty-six 
hours, the probability of a fatal termination is materially 
lessened. I have never seen a case of cerebral haemorrhage 
that was instantaneously fatal, and, although from anatomi- 
cal and physiological considerations I admit the possibility 
of such instances, I am persuaded that they must be rare. 
Jaccoud 1 expresses the opinion that death is immediate in 
those cases in which the haemorrhage is in the medulla ob- 
longata, or in those which occur in both hemispheres. Dr. 
Hughlings Jackson, 2 on the contrary, though conceding from 
theoretical grounds that haemorrhage into or near the me- 
dulla oblongata might cause instant death, has never wit- 
nessed such a termination ; and Dr. Wilks 8 says that apo- 
plexy is very rarely, if ever, a suddenly fatal disease, no 
matter what part of the brain may be the seat of the effusion. 
Among the reports of several thousand post-mortem exami- 
nations at Guy's Hospital, there was but one in which death 
was asserted to have been instantaneous, and that was a case 
of meningeal haemorrhage. Even this was doubtful, for the 
patient had fallen, some distance from the hospital, and was 
brought in dead. 

I have several times had cases under my observation in 
which, it was said, death had been as sudden as though the 
individual had been struck by lightning ; but careful inquiry 

1 Traite de Pathologie Interne. Paris, 1870. Tome premier, p. 166. 

2 On Apoplexy and Cerebral Haemorrhage. Reynolds's System of Medicine. 
London, 1868. Vol. ii., p. 620. 

3 Guy's Hospital Reports, 1866, p. 178. 



CEREBRAL HAEMORRHAGE. 77 

and post-mortem examination have either shown that the 
observers were deceived, or that there had been no extrava- 
sation at all, death being the result of heart-disease. 

In the majority of cases attended with complete loss of 
consciousness, the course of the disease is not so rapid or 
hopeless as in the form just described. The patient falls, is 
comatose, breathes stertorously, and presents a similar gen- 
eral appearance, but after a time consciousness begins to re- 
turn, and it is possible to partially rouse him from the con- 
dition of insensibility. He turns over in the bed, though 
with difficulty, and may attempt to speak. Articulation is, 
however, indistinct, for the muscles of one side of the face 
are paralyzed, and the tongue, from a like cause, is restricted 
in its movements. The paralysis is found to exist in the 
limbs of the same side, and involves the loss of sensibility, 
as well as of motion, though rarely to the same extent. In 
some exceedingly rare cases, perhaps not clearly understood, 
the paralysis of the limbs is on the opposite side to that of 
the face. A man thus affected was present at my clinic, in 
October, 1870, at the Bellevue Hospital Medical College. 
He was a patient under my charge at the New York State 
Hospital for Diseases of the Nervous System, and had been 
attacked several years previously. His history, as elicited 
with great care by my clinical assistant and resident physi- 
cian of the hospital, Dr. Cross, was perfectly clear on this 
point. 

The facial paralysis presents several points of great in- 
terest in a diagnostic point of view. The affected side is 
incapable of expression, but, so long as the patient does not 
attempt any facial movements, scarcely any distortion is per- 
ceived. Should he endeavor to open his mouth to spit or to 
puff out his cheeks, the paralysis is at once perceived. Ow- 
ing to the fact that the antagonism of the muscles is de- 
stroyed, the face is drawn toward the sound side, the angle 
of the mouth being slightly depressed. It is remarkable, 
however — and the fact is of importance as a diagnostic mark 



78 DISEASES OF THE BRAIN. 

between the facial paralysis of cerebral hemorrhage with 
hemiplegia and the simple facial paralysis from injury or 
disease of the eighth pair — that the patient does not lose the 
ability to close the eye of the affected side. 

If the fifth pair of nerves is involved in the lesion, sen- 
sibility is impaired, which is never the case in simple facial 
paralysis, and the masseter and pterygoid muscles, which 
receive their motor influence from this nerve, will conse- 
quently be paralyzed. The ability to masticate on the 
affected side is therefore lost, and the cheek hangs lower 
than on the sound side. 

The tongue is also only paralyzed upon one side. When, 
therefore, it is protruded from the mouth, the point deviates 
toward the paralyzed side, owing to the uncompensated ac- 
tion of the sound genio-hyoglossus. 

All these paralyses occur on that side of the body oppo- 
site to the seat of the lesion. The muscles are relaxed ordi- 
narily, though sometimes they are in a state of tonic rigidity. 
Generally, however, rigidity, when it exists, is in the mus- 
cles of the non-paralyzed side. 

The temperature of the affected side, as determined by 
the thermometer placed in the axillae, is at first higher than 
on the sound side, but at a subsequent period it becomes 
lower. 

It is rarely the case that the third nerve is affected. 
When it is, there is external strabismus from paralysis of the 
internal rectus muscle, and ptosis from paralysis of the ele- 
vator of the upper eyelid. The pupil is dilated, and is insen- 
sible to light. 

Another phenomenon is sometimes observed, and that is 
the rotation of both eyes toward the sound side. This is ac- 
companied by a like movement in the head, so that, if the 
patient is paralyzed on the left side, the eyes and head are 
turned to the right, and consequently, as the patient lies in 
bed, the right side of the face rests on the pillow. I have 
observed these symptoms in about one-third of the cases of 



CEREBRAL HEMORRHAGE. 79 

cerebral haemorrhage which have come under my observa- 
tion. They were present from the very beginning, and dis- 
appeared in a few days. 

Slight convulsive or involuntary movements are occa- 
sionally noticed. The most frequent of these is yawning, a 
symptom which Dr. Todd 1 regards as troublesome, and even 
unfavorable, but which, in my experience, is not very annoy- 
ing or dangerous. The other convulsive actions may be on 
the whole of either side of the body, or on both sides, or may 
be restricted to a single limb or even a group of muscles. 

Keflex movements can always be excited, especially in 
the lower extremity, by tickling the sole of the foot. Deg- 
lutition, though imperfect, can generally be made to take 
place by reflex action, unless, as previously stated, the haem- 
orrhage is in, or in the vicinity of, the medulla oblongata. 

In the less severe apoplectic form of cerebral haemorrhage 
now under consideration, the urine and faeces are sometimes 
passed involuntarily from paralysis of the sphincters, and 
are at times obstinately retained from paralysis of the blad- 
der and abdominal muscles. 

The mental symptoms are at first scarcely distinguish- 
able from those which are present in the severest form of 
the disease. The coma and insensibility are complete, but 
after a time, which varies in duration with the extent of the 
lesion, consciousness begins to return. The patient opens 
his eyes, and gives a little attention when loudly spoken to ; 
and is perhaps able to express, to some extent, his wishes by 
signs and gestures. Gradually the mental power increases ; 
he attempts to speak, but his words are misplaced or forgot- 
ten, and his articulation, owing, as already stated, to the pa- 
ralysis of the face and tongue, is thick and indistinct. Those 
words which are enunciated by the movements of the lips 
and tongue are especially troublesome, while those formed in 
the throat are not difficult to pronounce. 

The mental characteristics of the patient will be found 

1 Clinical Lectures. Second edition. London, 1861, p. 708. 



80 DISEASES OF THE BRAIN. 

to have undergone a radical change. He is irritable, unrea- 
sonable, and fretful. His sense of the proprieties of life, 
which may in health have been very delicate, becomes ob- 
tuse; his memory is notably impaired, and his reasoning 
power greatly diminished. The greatest change, however, 
is perceived in the emotional faculties. He laughs at the 
veriest trifles, and sheds tears profusely at the least circum- 
stances calculated to annoy him. Even for years afterward 
this peculiarity is noticed. 

Such is the first stage of an attack of cerebral haemor- 
rhage marked by apoplexy and paralysis, as ordinarily ob- 
served when amendment takes place. It is often the case, 
however, that this stage is not fully developed, owing to the 
continuance of the haemorrhage. In such an event the coma 
becomes more profound, the breathing more irregular and 
less frequent, the pulse intermits and loses in force, the face 
becomes purple from imperfect aeration of the blood, and 
death ensues. In other cases a certain degree of improve- 
ment may be attained, and then the haemorrhage may recur, 
and the patient dies comatose. Taking, however, a case in 
which the improvement has been progressive up to the point 
of partial resumption of the mental faculties, we find that a 
second stage characterized by different symptoms often super- 
venes. This is the period of inflammation. 

It may begin at a variable time after the occurrence of 
the extravasation, usually not later than the eighth day. It 
is marked by febrile excitement and pain in the head, the 
latter being often very severe. There is gastric derange- 
ment, as evidenced by nausea and vomiting ; and convulsive 
movements of the limbs, with contractions of the flexors of 
the paralyzed side, are generally present. Delirium is also 
a prominent feature. Sometimes there is obstinate wakeful- 
ness, and at others a strong tendency to coma. This stage 
may last three or four days, or at most five or six, when it 
either causes death by extension of the inflammation from 
the immediate vicinity of the lesion to other parts of the 



CEREBRAL HEMORRHAGE. 81 

brain, terminates in the formation of an abscess, or gradually 
ends in resolution, with abatement of the symptoms. 

Disregarding for the present the first two of these results, 
we proceed with the consideration of the phenomena of a 
case in which resolution takes place. 

With the cessation of the inflammatory action, the im- 
provement of the patient becomes very marked. His speech 
is every day more distinct, his mind more active, his para- 
lyzed limbs more capable of motion. Usually the leg recovers 
power with much greater rapidity than the arm, and thus 
the patient is able to walk tolerably well before he can raise 
his arm from his side, bend the elbow, or extend the fingers. 
The paralysis in the leg is most marked in those muscles whose 
office it is to elevate the foot, and this necessitates a peculiar 
gait in order to avoid dragging the toes along the ground. 
The abductors are rarely affected to any great extent. The 
patient in walking, therefore, throws the leg out from' the 
body, and then, swinging it around, clears the ground in this 
manner. 

In the upper extremity there is almost invariably a dis- 
position toward contraction of the pectoralis major and minor 
muscles, by which the arm is drawn across the front of the 
thorax. At the same time the latissimus dorsi, the trape- 
zius, the rhomboidei, the teres major and minor, are gener- 
ally in a state of relaxation, and eventually tend to atrophy. 
The elbow is slightly flexed, the wrist bent upon the forearm, 
and the fingers drawn in toward the palm of the hand. 
These actions may, in a great measure, be prevented by ap- 
propriate treatment, and they may vary in extent according 
to the gravity of the attack. It is a curious fact that the 
muscles of respiration are never paralyzed in cerebral haem- 
orrhage unless the medulla oblongate be insolved. 

Trousseau 1 has insisted, with great force, on the fact that, 
when the arm regains power before the leg, the termination 

1 Lectures on Clinical Medicine. Bazire's Translation. Part I. London, 
1866, p. 16. 



82 DISEASES OF THE BRAIN. 

is always fatal. That this is the general result, I ani very 
sure from my own experience, but it is not invariable, for 
there are now in the New York State Hospital for Diseases 
of the Nervous System two patients affected with cerebral 
haemorrhage whose arms have improved to a very great ex- 
tent, while the legs are still as much paralyzed as ever. 

Now, with all these troubles of motility, sensibility may 
likewise be affected to a greater or less extent. "When this 
is the case, the limbs of the affected side at first feel heavy as 
if made of lead, and after a while numbness, as exhibited by 
a feeling as if ants were crawling over the skin, or water 
trickling over it, as if pins and needles were sticking in it, 
or as if that part of the body were " asleep," is noticed. 
Sometimes the sense of touch is greatly lessened, while the 
ability to feel pain is scarcely impaired, and indeed is often 
considerably increased. Again, there may be hyperesthesia 
of the skin of the affected regions, and pain along the course 
of the nerves. 

The circulation is inactive in the paralyzed limbs, and 
this, together with the deficient nervous power, tends to 
cause a permanent reduction of temperature. The differ- 
ence may amount to as much as five or six degrees, and, as 
the ability to resist cold is diminished, the patient is obliged 
to use additional covering on the paralyzed members. 

From continued disuse, atrophy of the paralyzed mus- 
cles always takes place unless suitable treatment be begun 
at an early period. 

Thus far we have only considered those attacks of cere- 
bral haemorrhage which are accompanied with unconscious- 
ness. One of these forms kills, without the patient so far 
recovering as to show whether he is paralyzed or not, though 
of course he is so to a profound degree ; the other allows 
of more delay ; the brain can still act to some extent, and, 
if death does not ensue from continuance of the haemorrhage, 
the patient is found to be paralyzed on the side of the body 
opposite to the seat of the brain-lesion. One other form 



CEREBRAL HAEMORRHAGE. 83 

requires notice, and it is, perhaps, the one most frequently 
met with. It differs from the attacks just described, in the 
important fact that it is unattended with unconsciousness. 

Like the others, this species of cerebral haemorrhage may 
take place very suddenly, without premonitory symptoms, 
or it may, like them, happen while the patient is said to 
be asleep. Generally, however, though there may be no 
long prodromatic stage, there are symptoms occurring im- 
mediately before the attack which indicate both mental and 
physical disturbance. These are headache, vertigo, numb- 
ness, vomiting, irritability of temper, and, perhaps, slight 
difficulties of speech. 

"When the attack comes, the individual, if standing, falls, 
from the immediate paralysis of one leg. He is fully sen- 
sible of his condition, although there is generally more or 
less mental change. The arm and face are affected, and the 
speech is rendered impossible or is indistinct. 

If the patient be sitting or lying, he is aware that some- 
thing has happened, but does not discover its exact charac- 
ter till he attempts to rise. A distinguished general officer 
of the army, after a fatiguing day of ceremony, entered his 
carriage with his wife, to be driven to his hotel. As he 
passed along Fifth Avenue, he felt an indescribable sensa- 
tion, and immediately afterward noticed that he could only 
see the half of objects. He made no effort to speak, 
though he is confident he did not for a moment lose his 
consciousness. When he attempted to get out of the car- 
riage, he found, to his surprise, that he was paralyzed on the 
right side, and that his speech was so much impaired that 
he could not be understood. 

Another gentleman was reading an amusing book, at 
which he laughed heartily. He felt suddenly a feeling of 
vertigo, and the book dropped from his hand. He attempted 
to pick it up, but found he had lost power in the arm, and, 
on trying to call to his wife, who was in the same room, 
discovered that he could not speak. At this time he could 



84- DISEASES OF THE BRAIN. 

walk, but in a moment or two afterward he fell, from pa- 
ralysis of his leg. So far as the paralysis is concerned, I 
have rarely seen a more severe case than this. 

Another went to bed, perfectly well, to all appearance, 
having enjoyed uninterrupted good health for several years. 
In the morning he arose, but felt a little pain in his head. 
As he stood before his glass, he thought his face was slightly 
twisted, and he noticed as he was shaving himself that he 
did not feel the razor on one side. While he was testing 
his facial mobility and sensibility, he experienced a trace 
of numbness in his left hand. This gradually increased, 
and in addition the limb lost power. In a few minutes he 
could not move it at all. By the time I saw him — two hours 
afterward — the paralysis had extended to the leg. At no 
period was there insensibility or mental confusion. 

A gentleman retired at night in good health. On at- 
tempting to get out of bed he discovered that he was par- 
alyzed in the leg. Neither the arm nor the face was af- 
fected. 

Several cases have been under my care in which only the 
face or the tongue was paralyzed ; others in which the arm 
alone was involved ; and others, like the one just mentioned, 
in which the symptoms were confined entirely to the leg. 
Sometimes there was a momentary feeling of vertigo, some- 
times a vacant stare, something like that of the jpetit mal of 
epilepsy, sometimes a slight degree of intellectual confusion, 
sometimes headache, and, again, no head-symptoms whatever. 
The subsequent progress of such attacks requires no special 
consideration beyond that already given to the more severe 
forms. 

Now, no matter how light the attack may have been, nor 
how rapid the improvement, the patient who has had cere- 
bral haemorrhage is never mentally or physically the same 
as he was before. If the seizure has been severe, he may 
advance so far toward a complete cure as to evince very little 
disorder of his mind or body. But close observation shows 



CEREBRAL HEMORRHAGE. 85 

that he is not entirely restored, and, though he may do 
very well for light intellectual and physical exertion, se- 
vere labor of either kind is beyond his powers — and no 
one is more sensible of this fact than himself. Even after 
years his emotions are abnormally excitable. A patient now 
in the New York State Hospital for Diseases of the Nervous 
System informs me that he sheds tears every time a funeral 
passes him, and that even hearing of any one's death, or 
reading the obituary column in a newspaper, causes his feel- 
ings to get the better of him. In the lightest forms of the 
attack, this easily-aroused emotional disturbance is a marked 
feature for years subsequently, if it ever entirely disappears. 
And as regards the muscles which have been paralyzed, it 
is very certain that, though they may be made strong enough 
for all practical purposes, they never can be restored to their 
former sound condition. 

The character and general mental type of the individual 
usually undergo some change ; and this may be to the ex- 
tent of reversing his ordinary traits. 

Causes. — Advanced age is one of the most influential cir- 
cumstances which predispose to an attack of cerebral hsem- 
orrhage, and this fact has long been known. Thus Hip- 
pocrates ' states that apoplexy is most common between the 
ages of forty and sixty, and modern investigation estab- 
lishes the truth of the proposition as regards the actual 
number of cases. It is probable, however, that the liability 
increases, as Dr. Flint 2 says, from the age of twenty up- 
ward, and that there are not so many cases occurring in per- 
sons over sixty as below, for the reason that the number of 
individuals alive of that age is less. 

Of two hundred and twenty-nine cases of cerebral haem- 
orrhage which have been under my professional care during 
the last five years, two hundred and four occurred in persons 

1 Aphorisms, chapter vi., aph. 57. 

2 " A Treatise on the Principles and Practice of Medicine." Third edition. 
Philadelphia, 1868, page 582. 



86 DISEASES OF THE BRAIN. 

over forty years of age. Of these, one hundred and seventy- 
two were between forty and sixty, twenty-four between 
sixty and seventy, five between seventy and eighty, and 
three over eighty. 

Of the twenty-five cases in persons under forty, seven- 
teen were between forty and thirty, seven between thirty 
and twenty, and one under twenty. This latter was a boy 
of seventeen, whom I exhibited at my clinic at the Bellevue 
Hospital Medical College in the autumn of 1870. 

The disease is certainly more common among men than 
women, though some authors have asserted the contrary. 
Falret ascertained that, of twenty-two hundred and ninety- 
seven cases, sixteen hundred and sixty occurred in males and 
only six hundred and thirty-seven in females. In my own 
experience, of two hundred and twenty-nine cases, one hun- 
dred and fifty-three were in males and seventy-six in fe- 
males. 

Temperament and organization are supposed to have an 
influence in predisposing to cerebral haemorrhage. It was 
formerly thought that those of sanguine temperament and 
plethoric habit who had stout bodies, large heads, florid 
complexions, and short, thick necks, were especially liable ; 
but more exact and thorough investigation would appear to 
show that such is not the case, and that thin and pale indi- 
viduals show fully as great a proclivity. Dr. Flint l ex- 
presses the opinion that there is no special apoplectic consti- 
tution, and my own experience is decidedly to the same 
effect. 

That the tendency to cerebral haemorrhage is often heredi- 
tary, appears to be very certainly established. Within my 
own knowledge, I am aware of several striking instances 
which support this opinion. A gentleman consulted me 
for hemiplegia, the result of cerebral haemorrhage, whose 
grandfather, father, two uncles, two brothers, and one sister, 
had died of this disease, and whose son, thirty-six years of 

Op. cit., p. 583. 



CEREBRAL HEMORRHAGE. 87 

age, had been attacked. In another case a lady had her 
father, two brothers, and one sister, die of the disease ; and, in 
a third very remarkable case, the great-grandfather, grand- 
mother, father, four uncles and aunts, and two brothers, all 
in a direct line, died of cerebral haemorrhage. 

Piorry 1 cites the case of a woman, herself paralytic, 
whose three children had died of convulsions, and whose 
mother, uncle, and brothers and sisters, to the number of 
twelve, had died of cerebral haemorrhage or convulsions. It 
has very often happened in my experience that the father 
or mother of a hemiplegic patient, whose condition resulted 
from cerebral haemorrhage, had been affected in a similar 
manner. 

As regards the influence of diseases of the heart, Legal- 
lois, Brichteau, Rostan, Andral, and Bouillaud, 3 adduce in- 
stances in support of the existence of a definite relation. 
"While others, among whom Rochoux, Walshe, and Flint are 
to be placed, deny the existence of any causative influence. 
As tending to produce active or passive cerebral congestion, 
disease of the left or right side of the heart would reasonably 
seem to be conducive to the occurrence of cerebral haemor- 
rhage. The tension of the blood in the vessels of the brain 
is increased thereby, and the liability to the rupture of a dis- 
eased vessel rendered greater. 

The condition of life has also been supposed to exert an 
effect in predisposing to cerebral haemorrhage, it being as- 
serted by some authors that the affection is much more 
common with the rich, and those living in ease, luxury, and 
refinement, than in the poor and laboring classes. 

It is difficult to arrive at any very definite conclusion on 
this point, owing to very obvious reasons, but I am inclined 
to think the theory to be not well founded. It is only ne- 
cessary to visit our large hospitals, to see how many of the 
inmates, drawn as they generally are from the laboring 

1 De l'Heredite dans les Maladies, p. 107. 

2 Traite de Clinique des Maladies du Coeur, 2d edi., t. ii., p. 580 



88 DISEASES OF THE BRAIN. 

classes, are suffering from cerebral hemorrhage or its ef- 
fects. 

Thus far we have only considered the more important, 
intrinsic, predisposing causes; there are, however, others 
which may be called extrinsic. 

Season is one of the chief of these. The disease is much 
more common in winter than in the other seasons, although 
some statistics would seem to show more cases during sum- 
mer. A careful examination of such, however, shows that 
under the head of apoplexy are included not only cerebral 
haemorrhage, but congestion, sunstroke, embolus, and in 
fact nearly every other affection attended with sudden loss 
of consciousness. My own researches have been very exact 
on this point, and as their results I find that, of the two hun- 
dred and twenty -nine cases of which I have notes, eighty- 
five occurred in winter, forty-one in spring, fifty-six in sum- 
mer, and forty-seven in autumn. It has been noticed, too, 
that sudden variations of temperature, especially from mild 
to cold weather, increase the number of cases of cerebral 
hasmorrhage. 

Of the exciting causes, a long list can readily be made. 
Among them are the excessive use of alcoholic liquors and 
other stimulating substances, the use of opium in excess ; the 
ingestion of large quantities of food, especially such as is 
stimulating and indigestible; excessive physical or mental 
exertion, strong emotional disturbance, such as anxiety, ex- 
treme joy, anger or terror ; the act of coition, especially in 
old people ; straining at stool ; enlarged prostate, or paralysis 
of the bladder, requiring strong muscular efforts for the evac- 
uation of the urine ; childbirth ; tight clothing about the 
neck, chest, or abdomen ; certain occupations which require 
the head to be depressed ; vomiting, sneezing, coughing, and 
laughing ; exposure to the direct rays of the sun or other 
sources of great heat ; the sudden arrest of a customary flux, 
such as hsemorrhoidal bleeding ; the sudden application of 
cold water to the body ; long-continued bathing in very 



CEREBRAL HAEMORRHAGE. §9 

warm water; the circumstance that the patient has had a 
previous attack, and certain diseases, as gout and syphilis. 

In regard to some of these causes, I may state that sev- 
eral very interesting cases have occurred in my own prac- 
tice. In one, a lady was attacked on hearing that her cook 
had left her, in another the emotion excited by the fall of a 
picture from the wall caused a seizure. Four cases pro- 
duced bv straining; at stool have come under mv observation. 
In one of them a gentleman well known in public life re- 
tained sufficient consciousness and intelligence to take a 
large key out of his pocket with the non-paralyzed hand, and 
to rap on the floor for assistance. 

Two cases occurred during sexual intercourse, one in a 
man, the other in a woman. In one of these there was, sub- 
sequently, a great increase of venereal desire. In one case, 
the seizure was induced by stooping over to tie the shoe. 
This was in the boy, seventeen years of age, already men- 
tioned. It must be confessed, however, that very frequently, 
perhaps in the majority of cases, no immediate cause can be 
reasonably alleged. Of the two hundred and twenty-nine 
cases noted by myself, no cause was noted in one hundred 
and fifty-three. 

Relative to the influence of sleep, I am by no means in 
accord with those authors who regard it as a powerful, ex- 
citing cause. During sleep the quantity of blood circulating 
in the cerebral blood-vessels is diminished, and hence there 
is less tension upon their walls than during wakefulness. 
I doubt very much whether cerebral haemorrhage ever oc- 
curs during healthy, undisturbed sleep. 

But there is a condition which supervenes upon sleep, and 
which, to ordinary observers, presents the usual phenomena 
of sleep, but which is really a very different state, both as re- 
gards the brain and the symptoms — and that is stupor due 
to venous congestion. In this affection there is an increase 
of the pressure upon the brain, produced by the over-dis- 
tended vessels ; and hence coma, to some extent, ensues. 



90 DISEASES OF THE BRAIN. 

This state is characterized by difficulty of awaking the indi- 
vidual, by tnrgescence of the larger veins of the neck, by a 
more or less purple hue of the face, by snoring, and by the 
puffing out of the lips and cheeks in breathing. Both of 
these latter phenomena are due to paralysis. 

In this condition it is not unusual for cerebral haemor- 
rhage to occur, but the existing state is not sleep. 

So far as my own experience extends, I have not found 
a majority of the cases, where I have examined into this 
point, to have taken place either during sleep or the stupor 
to which I have referred. I have made it a rule, not only 
in those cases of cerebral haemorrhage which have been 
under my own care, but all others, in which I could do so, 
to inquire particularly with reference to the matter in ques- 
tion, and have found that, in two hundred and fifty-five 
out of three hundred and forty-two cases, the individuals 
were awake at the time of the attack. 

Doubtless much of the confusion has arisen, not only 
from the non-discrimination of sleep with stupor, but also 
from treating of apoplexy as a disease instead of regard- 
ing it as a symptom due to several very different pathological 
conditions of which cerebral haemorrhage is only one, and 
of which embolism, thrombosis, congestion, meningeal haem- 
orrhage, and epilepsy, are others. 

Finally, it may be said of the etiology, that whatever 
tends to increase the flow of blood to the head, or to retard 
its exit, is capable of acting as an immediate cause of cere- 
bral haemorrhage. 

Diagnosis.— The diagnosis of cerebral haemorrhage is or- 
dinarily not difficult, but it must be confessed that one or 
two affections are very liable to be confounded with it, and 
the attendant circumstances surrounding a patient in a con- 
dition of insensibility may be such as to materially increase 
the obstacles to the formation of a correct opinion. 

Thus, supposing an individual to be found in a state of 
profound insensibility, the condition may be due to compres- 



CEREBRAL HEMORRHAGE. 91 

sion from injury of the skull, to concussion from a fall 
or blow, to congestion, to asphyxia, to syncope, to a recent 
epileptic fit, to uraemic intoxication, to hysteria, to narco- 
tism, or to drunkenness. 

A mistake of either of these states for cerebral haemor- 
rhage would be, in the end, embarrassing to the physician, 
and, perhaps, injurious to the patient. 

The coma might also be the result of embolism, of throm- 
bosis, of tumor, of abscess, or of meningeal haemorrhage; but, 
as regards these conditions, no opprobrium could be attached 
to the physician, or harm come to the patient, by any error 
of diagnosis, although a regard for scientific exactness should 
always prompt us to be as specific as possible in our in- 
quiries and examinations. 

From asphyxia, cerebral haemorrhage is distinguished 
by the fact that in the former the respiration is suspended. 
The cause is also often apparent. A careful examination 
of the cranium, and a survey of the surrounding circum- 
stances, will enable the physician to ascertain the existence 
or non-existence of compression from traumatic cause. 
This cause may either be depression of bone, the rupture 
of an internal blood-vessel, or the entrance of some foreign 
body, as a bullet, into the interior of the skull. So far as 
symptoms are concerned, there might be considerable diffi- 
culty in diagnosticating either of these accidents from cere- 
bral haemorrhage, but the history would render a mistake 
impossible. 

Concussion presents more difficulties, because the coma- 
tose person may be found in such a situation as to warrant 
the opinion that he has fallen from a height, or otherwise 
received a blow on the head, when in fact he is suffering 
from cerebral haemorrhage. But if he has fallen from a 
height or been struck, there will probably be more severe 
bruises about his person than if he is affected with cerebral 
haemorrhage, and there may be bleeding from the ears or 
nose — symptoms of cranial injury not met with in the latter 
condition. 



92 DISEASES OF THE BRAIN. 

If, however, the individual has fallen from a height, he 
may have done so in consequence of an extravasation of 
blood in his brain, and he may r present all the marks of suf- 
fering simply from the concussion, or he may have fractured 
skull with compression. It is, therefore, impossible to make 
a correct diagnosis in all cases, or to lay down any certain 
rules which will constitute infallible guides. It is perfectly 
possible to meet with cases such as those referred to, in re- 
gard to which no human judgment can be certainly correct. 
Such instances are of course rare, and accordingly, in the 
great majority, the circumstances and the presumption will 
generally lead to a correct opinion. 

From congestion of the apoplectiform variety cerebral 
haemorrhage can generally be distinguished without much 
difficulty. The absence of stertorous breathing, the short 
duration of the coma, the transient character of the paraly- 
sis, the contraction of the pupils, the fact that the loss of 
sensibility and the power of motion are not generally con- 
fined to one side of the body, and the longer continuance 
of premonitory symptoms, will be sufficient indications of 
the existence of congestion. Syncope is distinguished by 
the circumstances that the respiration and circulation are 
both diminished in power if not suspended, that there is no 
hemiplegia, that the face is pale, the skin cold, and that these 
phenomena are all transitory in character. The history of 
the case will also assist us in arriving at a correct judgment. 

Epilepsy, if seen from the beginning of the paroxysm, 
cannot be mistaken for cerebral haemorrhage, nor this latter 
for epilepsy, if the onset of the attack has been witnessed. 
But a person found in a comatose condition, with no previ- 
ous history to guide us, may be supposed to be either in the 
comatose stage of an epileptic paroxysm, or to be laboring 
under a seizure due to extravasation of blood. In such 
a case, if the fit has been epileptic, foam will be found 
around the mouth, and perhaps blood from injury of the 
tongue or cheek. Moreover, the stupor of epilepsy is not 



CEREBRAL HEMORRHAGE. 93 

usually of long duration, and is not generally characterized 
by stertorous breathing. 

In uraemia, the coma of which is very similar to that 
resulting from cerebral haemorrhage, the history of the case 
is our chief reliance for a correct diagnosis, though the ab- 
sence of hemiplegia and the general presence of anasarca 
are of course of great value. Moreover, in very doubtful 
cases the urine may be drawn off by the catheter, and exam- 
ined for albumen and tube-casts. If these are present, the 
probability of the stupor being due to Bright's disease and 
uraemic intoxication is very much increased. 

Coma is sometimes a manifestation of hysteria, but a 
very little acquaintance with the phenomena of this condi- 
tion will suffice to prevent mistakes. In some cases of hys- 
terical coma there is well-marked hemiplegia ; but even 
when this complication is present, the facts that the hyster- 
ical diathesis exists, that there have probably been other 
manifestations of hysteria, that the pulse is small, weak, and 
frequent, and that the breathing is free from stertor, will 
enable a correct diagnosis to be formed. 

In narcotism the condition often bears a close resem- 
blance to that due to cerebral haemorrhage. But in the 
former there is no hemiplegia, the pupils are generally con- 
tracted, the respiration is not stertorous, and the coma comes 
on gradually. 

Drunkenness and cerebral haemorrhage are often con- 
founded. I have known some sad mistakes of the kind to 
be made, both by professional and non-professional persons, 
many of which were unavoidable, for it must be confessed 
that there are great difficulties connected with the subject. 
The habit of drinking alcoholic liquors is so general that no 
reliance can be placed upon the test of smelling the breath. 
A person may have just taken a glass of wine or of brandy, 
and be seized with extravasation of blood in his brain im- 
mediately afterward, and when not in the least intoxicated. 
And, even if dead-drunk, he may at the same time have 



94: DISEASES OF THE BRAIN. 

cerebral haemorrhage. In such a case as the latter, discrimi- 
nation would be impossible. In ordinary cases of alcoholic 
intoxication the patient can generally be roused to some 
extent ; the pupils are dilated, but this latter is often the 
case in hsemorrhage ; the breathing is usually free from 
stertor, but some drunkards always snore ; the pulse is 
small and weak, and there is no hemiplegia. When all 
these symptoms are in accord, there will be little difficulty ; 
when they are not, the physician must be guarded in his 
expressions of opinion, and diligently inquire into the per- 
sonal characteristics of the patient and all matters bearing 
on the history of the case. 

From the centric diseases previously mentioned, the 
diagnosis of cerebral hsemorrhage is easy as regards some, 
and difficult as to others. Thus, from embolism it cannot 
in many cases be distinguished in the first stage. But when 
all the phenomena are taken into consideration the chance 
of error is very much diminished. Embolism is generally 
accompanied with disease of the left side of the heart, and 
there is often a history of rheumatism ; there are never any 
premonitory head-symptoms ; it occurs in young persons as 
well as old ; for reasons which will be explained when the 
subject of partial cerebral anaemia from embolism is consid- 
ered, the resulting hemiplegia is generally on the right side ; 
the paralysis generally disappears in a few hours after the 
attack ; if it does not, there is no gradual improvement, as 
in cerebral haemorrhage ; there are no contractions or partial 
convulsions, 1 and there is more frequently delirium. 

The gradual development of the symptoms in thrombosis, 
tumor, or abscess, and the frequency with which convul- 
sions ensue in the latter diseases, together with the asso- 
ciated symptoms, will prevent the coma which sometimes 
exists being mistaken for the stupor of cerebral haemorrhage. 

1 Jaccoud (op. cit., p. 141) so asserts, though I have seen one case in which 
post-mortem examination revealed the presence of an embolus in the middle 
cerebral artery, and in which there had been convulsions. 



CEREBRAL HAEMORRHAGE. 95 

During the subsequent stages of cerebral haemorrhage, 
when the mental condition and the hemiplegia are the most 
prominent features, inquiry into the antecedent history will 
bring out the foregoing points, and assist us in arriving 
at a correct idea of the cause. Even, however, should we 
be baffled in this respect, no great inconvenience could re- 
sult either to the patient or physician. 

Prognosis. — The prognosis depends upon the extent of the 
haemorrhage, and refers to the probability of saving life 
during the period of attack and immediately afterward, and 
of curing or mitigating the subsequent paralysis. 

In the severe apoplectic form, death is almost inevitable ; 
so far as my experience goes, it is the invariable result. It 
generally takes place within a few hours. If, however, 
life be prolonged till the fourth clay, there is some hope. 
Irregularity of pulse, or one very rapid, impossibility of 
swallowing, involuntary evacuation of the faeces, and cold 
sweats, render, if possible, the prognosis still more unfavor- 
able. 

In the apoplectic form attended with paralysis, the grad- 
ual increase of the coma and hemiplegia indicate the con- 
tinuance of the haemorrhage, and are consequently of grave 
importance. About one-third of those attacked with this 
form die. The prognosis is bad in accordance with the 
strength and age of the patient, and the circumstances under 
which the attack has occurred. Thus, if it has supervened 
in a person who has had no obvious exciting cause, the 
probability is that there is serious disease of the blood-ves- 
sels, whereas, coming on in a young person as the result of 
severe muscular exercise, or mental strain, the prognosis is 
more favorable. A second attack is more apt to prove fatal 
than a first, and a third than a second, and so on. 

In the mild form characterized by paralysis, but no 
loss of consciousness, the prognosis is generally favorable. 
It must be recollected, however, that the risk of inflamma- 
tion is quite great, both in this and the apoplectic form with 



96 DISEASES OF THE BRAIN. 

paralysis, and that the patient is not safe from it till after 
the eighth day. 

And in both forms, if the temperature rise above 100° 
Fahr., if the respiration be chiefly abdominal, and rattling 
of mucus is heard in the throat, the prospect of recovery is 
bad. The same may be said of pain in the head and con- 
tractions of the paralyzed muscles. 

As regards the probability of recovery from the paraly- 
sis, much depends upon the opportunities the patient may 
have for receiving proper medical treatment. The ten- 
dency is generally toward amendment even in the worst 
cases. Gradually the speech improves, the breathing be- 
comes better, and the arm acquires more strength ; but the 
improvement often stops now, and never goes on unaided to 
complete recovery. The longer the paralysis has lasted, the 
less prospect there is of great progress under any treatment, 
and, if strong contractions producing distortions have taken 
place, the prognosis is unfavorable. 

Certain muscles recover better than others. The exten- 
sors of the foot and hand are especially intractable, but, as 
a rule, those of the lower extremity improve more rapidly 
than those of the upper. 

The mind ordinarily improves, jpa/ri passu with the phys- 
ical symptoms, though not always. I have witnessed several 
exceptions to the rule. Even in slight cases the intellect 
may suffer to a great extent, and in no case is it ever in all 
respects as good as before the attack. Among the unfavor- 
able signs are persistent iritability of temper, failure of 
memory, and the existence of delusions. Difficulties of 
speech, whether as regards the memory of words, or the 
ability to coordinate the muscles of speech so as to pro- 
nounce them properly, are often very persistent. I have 
now under my care a gentleman who was attacked with 
cerebral haemorrhage two years ago, whose physical pow- 
ers are quite good, and whose mind is not seriously im- 
paired, but who cannot yet remember sufficient words to 



CEREBRAL HEMORRHAGE. 97 

carry on an ordinary conversation. When the difficulty is 
simply due to paralysis of the tongue and facial muscles, 
the prognosis is more favorable. 

Morbid Anatomy. — The seat of the extravasation from 
cerebral haemorrhage may be in the substance of the cerebral 
tissue, or in the ventricles. The former is much the more 
common. 

Now, the blood which is poured out from a ruptured ves- 
sel into the substance of the brain must, of course, occupy 
its place by separating or lacerating the fibres. It thus 
forms for itself a cavity which enlarges as the haemorrhage 
goes on, until at last the resistance to further separation or 
laceration may be so great as to overcome the tension of the 
blood, and thus put a stop to the bleeding. 

The shape of the cavity varies according to the manner 
by which it has been produced. When it is formed by the 
separation of the cerebral fibres, it is generally elongated ; 
whereas, when produced by laceration, it is oval, round, or 
irregular in form. The situation of the haemorrhage modi- 
fies the form of the cavity. In the hemisphere it is usually 
round, in the motor tract irregular or oval. The variations 
as regards size are great. I have seen clots no larger than 
a pea, and again as large as an orange. When haemorrhage 
occurs in the motor tract, the clot is almost invariably small ; 
whereas, in the hemispheres, in the cerebellum, or in the 
ventricles, it is large. 

A clot does not always consist of blood alone. Brain- 
tissue is very often mixed with it, and this is especially the 
case when the extravasation has been in the hemispheres. 

The ordinary seat of cerebral haemorrhage is the motor 
tract, and especially the corpus striatum and optic thalamus. 
The crus cerebri may also be the seat of the extravasation, 
though not often primarily. 

When the haemorrhage occurs in the mesial line of the 
pons varolii, the paralysis is, of course, on both sides of the 
body. Two cases of the kind have occurred in my practice, 
1 



98 DISEASES OF THE BRAIN. 

and both were from severe blows on the skull. One side 
of the pons is more frequently the seat. 

The medulla oblongata is not often involved, though a 
few cases are on record. 

The hemispheres and the lateral ventricles are occasion- 
ally the seats of extravasation, the cerebellum rarely. 

Extravasated blood undergoes certain changes. Instead 
of separating into two parts, the clot and the serum, as does 
blood when exposed to the atmosphere, it remains for a time 
homogeneous and gelatiniform. About the fifth or sixth 
day it separates into two parts : the one, the serum, is ab- 
sorbed by the surrounding tissue ; the other, consisting 
mainly of the fibrine and the red corpuscles, contracts and 
becomes hard. By the fifteenth day it has become fibrinous 
in texture, and is changed from its former black hue to a 
yellow color. Microscopic examination, made at any period 
during these changes, reveals the presence of red corpuscles, 
crystals of hematoidin and sometimes of cholestrin. It 
never entirely disappears. 

In the early period of the extravasation, the walls of the 
cavity are rough, and discolored with blood. But, as the 
changes are going on in the clot, the walls likewise alter in 
appearance ; the inequalities and irregularities disappear, 
and a new formation of connective tissue lines the cavity. 
Blood-vessels appear in it, and aid in the absorption of the 
fluid portion of the extravasated blood. As the process of 
separation and absorption goes on, the cavity contracts upon 
its contents, and eventually forms a cicatrix which encloses 
the remains of the clot. This cicatrix is generally of a yel- 
low color, and firm in texture. 

Sometimes, however, absorption does not take place. 
The contraction of the walls of the cavity does not there- 
fore ensue, and it remains distended with more or less al- 
tered blood. This may be the starting-point of secondary 
lesions, or a new haemorrhage may occur into the same cav- 
ity, or an abscess may result. 



CEREBRAL HAEMORRHAGE. 99 

Pathology. — The theory of cerebral haemorrhage brings 
us to the consideration of several important points. One 
of the first questions to be solved is, Can the rupture of a 
vessel of the brain take place — not including traumatic 
causes — unless the vessel is in a diseased condition ? Both 
sides of this proposition have their adherents. On the one 
part, it is urged that cerebral haemorrhage never takes 
place spontaneously unless the walls of the bleeding vessel 
have been so injured by disease as to destroy their strength 
and elasticity ; on the other, that it is perfectly possible for 
a blood-vessel to give way, owing to increased tension of the 
blood or disease of the perivascular tissue, without the walls 
of the vessel itself being in the least diseased. While ad- 
mitting that, in the majority of cases, the structure of the 
yielding vessel will be found to be impaired, I am satisfied 
that either of the other two causes may produce a rupture. 
The reasons for this opinion will be apparent in the course 
of the folio wins; remarks. 

The most common disease to which the cerebral arteries 
are liable is chronic endarteritis, a condition which has been 
well described by Virchow, 1 and which is particularly apt to 
be met with in those who, from age or other debilitating 
influence, have had their nutrition impaired. As the con- 
sequence of this state, the vessels lose their elasticity, be- 
come brittle, and are therefore often unable to bear the ordi- 
nary tension of the blood, much less any severe strain. This 
disease may terminate in fatty degeneration of the arterial 
walls, or this last condition may be the primary affection. 
Fatty degeneration, like chronic endarteritis, is most com- 
monly met with in badly-nourished persons, but who are at 
the same time cachectic. The inner coat is the point of 
origin, and hence it sometimes happens that this and the 
middle coat give way, leaving the external coat entire, and 

1 Ueber die Erweiterung kleinerer Gefasse. Archiv fur Path. Anat. uud Phy- 
siol., B. III., 1848, and Cellular Pathology, London, 1860, Lecture XVI. 



100 DISEASES OF THE BRAIN 

tlins forming an aneurism. But Bouchard, 1 who has exam- 
ined into this matter with great minuteness, denies that 
such aneurisms are ever found, and asserts that the so-called 
aneurismal sac consists of the lymphatic membrane, lining 
the cavity in the perivascular tissue, through which the ves- 
sel passes, and that the blood, in such cases, has already 
ruptured the' vessel. In reality, however, there is no 
haemorrhage into the cerebral tissue till this membrane gives 
way. 

In a subsequent memoir, by MM. Charcot and Bouchard, 8 
this point is still more thoroughly considered, and the opin- 
ion expressed that cerebral haemorrhage is almost invariably 
due to these so-called miliary aneurisms, which are the 
result of arteritis, and which are not necessarily preceded by 
atheroma. 

In sixty-nine cases of cerebral haemorrhage in which 
post-mortem examinations were made, atheroma was found 
but in fifteen, or twenty-two per cent., while these miliary 
aneurisms were met with in every case. They appear as 
little globular masses in the small intracranial vessels, and 
are in size from one-tenth of a millimetre to one millimetre. 
If they contain liquid blood, they are red ; but, if the blood 
be coagulated, the color is dark, almost black in some cases. 
In the order of frequency, they are found in the optic thala- 
mi, the corpora striata, the convolutions, the tuber annulare, 
the cerebellum, the centrum ovale, the crura cerebri, and 
the medulla oblongata. 

The condition of the perivascular tissue, or the brain- 
substance, has much to do with the occurrence of haemor- 
rhage. One reason why extravasation more frequently oc- 
curs in the brain than in the liver, for instance, is that its 
tissue is softer, and therefore not capable of giving as much 

1 Etudes sur quelques Pointes de la Pathogenie des Hemorrhagies cerebrates. 
Paris, 1866. 

2 Nouvelles Recherches sur la Pathogenie de l'Hemorrhage cerebrale. Ar- 
chives de Physiologie Normale et Pathologique, 1868, pp. 110-643. 



CEREBRAL HAEMORRHAGE. 101 

support to the blood-vessels as is the latter organ. ]STow, 
when the cerebral substance is softened by disease in any 
part, the natural support of the vessels of that part is still 
further lessened, and the tendency to haemorrhage increased. 
Again, in the condition sometimes met with in old people, 
in which the brain becomes atrophied, the vessels may 
undergo dilatation and subsequent rupture. This view is 
opposed by Jaccoud, 1 but in one case of cerebral haemor- 
rhage, terminating in death, and in which I had the oppor- 
tunity of making a post-mortem examination, the right 
hemisphere, the seat of the extravasation, was very consid- 
erably atrophied, and weighed three ounces and a quarter 
less than the left. The possibility of the existence of this 
cause may, therefore, be admitted, although it 'cannot be 
considered as definitely established. The researches of Co- 
tard 2 would appear to show that cerebral haemorrhage is 
not infrequently a cause of partial atrophy of the brain. 

In the next place, the state of the blood, as regards qual- 
ity and tension, must be considered. There can be no doubt 
that certain diseases aifecting the general system may so 
deteriorate the blood as to render it unfit to properly nour- 
ish the blood-vessels, and hence their tissue is more readily 
broken down. Among these conditions are typhus, scurvy, 
chlorosis, and syphilis. 

The tension of the blood in the vessels is subject to con- 
stant variation from the operation of many physical and 
mental causes, and may, through their action, be so in- 
creased as to overcome the resistance afforded by the vascular 
walls. These influences have been sufficiently considered 
in the section on causes, and need not, therefore, be dwelt 
upon here at any length. My own opinion of their suffi- 
ciency, without preexisting disease of the blood-vessels, to 
produce rupture and extravasation, has been formed after 
much observation and reflection. Analogous phenomena 

1 Op. cit, p. 155. 

2 Etude sur 1' Atropine partielle du Cerveau, Paris, 1868. 



102 DISEASES OF THE BRAIN. 

take place every day, and are not supposed to be due, in 
any extent, to vascular disease. Thus nasal haemorrhage 
occurs from strong muscular exertion of such a character as 
to retard the flow of blood from the brain, from emotional or 
other kind of mental excitement, and from hypertrophy of 
the left side of the heart, by which the amount of blood in 
the cerebral vessels is increased. All these causes augment 
the tension, and it would be singular if at times a healthy 
intracranial vessel did not give way through their influence 
as well as one outside of the skull. 

A point of very great importance remains to be con- 
sidered as a part of the pathology, and that is whether it is 
possible or not to determine during life in what part of the 
brain an extravasation has taken place ? While I am afraid 
we cannot be as explicit in this matter as is desirable, I am 
very sure we can often, from a careful study of the symp- 
toms, arrive at conclusions more or less accurate, and can 
sometimes determine the question with absolute certainty. 
The great difficulty is, that we are not yet sufficiently ac- 
quainted with the physiology of the several parts of the 
brain, and hence are not able to ascribe, with as much sure- 
ness as is desirable, variations from healthy action to de- 
rangement of the proper anatomical part of the cerebral 
mass. 

As we have seen, haemorrhage is more liable to take place 
within the ganglia constituting the motor tract than any 
other part of the brain. This is mainly due to the fact that 
this is the most vascular part of the cerebral substance. 

When the lesion is limited to the corpus striatum of one 
side, there is loss of the power of voluntary motion on the 
opposite side, but no abolition of sensibility, except, per- 
haps, for a few hours. Cases in illustration of this fact have 
been given by Andral a and Luys, 2 and one instance in my 
own experience was established by post-mortem examina- 

1 Clinique Medicale, t. v., pp. 319-321, 442. 

2 Recherches sur le Systeme Nerveux Cerebro-Spinal, etc., p. 545. 



CEREBRAL HAEMORRHAGE. 103 

tion. The patient, a man sixty-two years of age, had been 
hemiplegic for eleven years, and died suddenly, in April, 
1851. Post-mortem examination showed the canse of death 
to have been fatty degeneration of the heart. On examin- 
ing the brain, a cicatrix was discovered in the right corpus 
striatum. The hemiplegia was on the left side, and had 
never been accompanied with any loss of sensibility. There 
was no other lesion of the brain, so far as could be ascer- 
tained. 

The optic thalamus is another common seat of extrava- 
sation. In such a case the observed symptoms are especial- 
ly connected with the organs of the special senses. Thus 
there are double vision, dilatation or convulsive movements 
of the pupil, blindness, and anaesthesia or hyperesthesia 
of the paralyzed parts of the body. As in lesion of the cor- 
pus striatum, the paralysis of motion, when it exists, is on 
the opposite side of the body. The hearing and smell may 
also be affected. Luys 1 has collected a large number of 
cases in support of the view here enunciated. 

It generally happens that an extravasation, originating 
in either the corpus striatum or optic thalamus, involves 
both these ganglia. Hence we have, as the most common 
symptoms of cerebral haemorrhage, loss or impairment of 
the power of motion, disturbance of sensibility, dilatation or 
irregular movements of the pupil, aberrations of vision, etc. 

"When the extravasation beginning in the left optic thala- 
mus or corpus striatum extends to the fissure of Sylvius so as 
to involve the posterior part of the third frontal convolution, 
the island of Reil, or other part supplied by the middle cere- 
bral artery, or when it originates in this region, aberrations 
of speech occur. These are independent of paralysis of the 
tongue, and are such as are embraced under the term 
aphasia. This subject will be hereafter more fully con- 
sidered. 

Haemorrhage into the crus cerebri produces hemiplegia 

1 Op. cit., p. 534, et seq. 



104 DISEASES OF THE BRAIN. 

of the opposite side, more or less extensive, according to the 
size of the clot, with loss of sensibility. The third pair 
arises in part from the crus, and hence may be paralyzed, 
producing ptosis and external strabismus on the side corre- 
sponding to the seat of the lesion, and consequently opposite 
to the hemiplegia. 

When the pons varolii is affected, the crossed paralysis 
is still more marked. The limbs are paralyzed on the oppo- 
site side, and the face in whole or in part on the same side 
as that in which the haemorrhage takes place. If the ex- 
travasation is in the mesial line, both sides of the body are 
paralyzed. According to Trousseau, 1 however, crossed paral- 
ysis is not always due to a lesion of the pons, as asserted by 
Gubler, 2 and as supported by additional cases collected by 
Luys. 3 Trousseau rests his opinion on one case in which 
after death very extensive lesions of the brain were found, 
but none involving the pons. 

The principal symptoms indicating the medulla oblongata 
as the seat of extravasation are, loss of the power of swal- 
lowing, from paralysis of the glossopharyngeal, difficulty of 
protruding the tongue, from paralysis of the hypoglossal, and 
huskiness of the voice, tumultuous action of the heart, dysp- 
noea and gastric derangements, from paralysis of the pneu- 
mogastric nerve. 

In lesions strictly limited to the ganglia cited, there is 
no aberration of the intellectual faculties. It is only when 
the gray substance of the cerebrum or cerebellum is involved 
that the mind participates. In those cases of cerebral haem- 
orrhage, therefore, attended with coma or other mental phe- 
nomena, we may be very sure that the gray substance of the 
organs mentioned is affected, and this may be either from 
the haemorrhage which has originated in the motor tract 

1 Lectures on Clinical Medicine, Bazire's Translation, part ii., p. 333. 
8 Sur l'Hemiplegie Alterne, Gaz. Hebd., October, 1856, and Memoire sur lea 
Paralysies Alternes, etc., Gaz. Hebd., 1859. 
3 Op. cit., p. 529, et seq. 



CEREBRAL HEMORRHAGE. 105 

being so extensive as to compress the cerebrum or cerebel- 
lum, or from an extravasation beginning in the first place in 
these ganglia. The researches I have made 1 relative to the 
functions of the cerebellum would seem to show that its 
office is not materially different from that of the cerebrum. 
Still, I think there are some indications which, although 
not perhaps giving us the right to form a definite conclu- 
sion, are yet sufficiently well marked to enable us to arrive 
at a probable diagnosis between hemorrhagic lesion of the 
cerebrum and that of the cerebellum. Thus, vertigo is almost 
an invariable accompaniment of the cerebellar extravasa- 
tion ; vomiting is much more generally met with than when 
the cerebrum is affected ; hemiplegia is not so common ; the 
sensibility is never disturbed ; and the pain is in the back 
of the head. 

Besides a number of cases, some of which are referred 
to in the memoirs cited, one has occurred in my experience, 
in which I had the opportunity of making a post-mortem 
examination. 2 

A man had suffered from vertigo, occasional convulsions, 
attacks of nausea and vomiting, and a constant and violent 
pain affecting the back of the head. The symptoms had 
ensued in consequence of a severe blow which he had re- 
ceived on the back of the head by raising himself too soon 
while the horse he was riding was passing under a low arch- 
way. 

When this man attempted to walk he reeled and stag- 
gered as if he were drunk. The upper extremities and the 
organs of speech were not affected ; he had the entire con- 
trol of his legs when lying down, and there was no diminu- 
tion of sensibility anywhere. At last he became paraplegic, 
and shortly afterward died in a convulsion. The post-mor- 
tem examination showed the existence of an abscess which 

1 The Physiology and Pathology of the Cerebellum. Quarterly Journal of 
Psychological Medicine, April, 1869. 

2 Op. cit., p. 209. 



106 DISEASES OF THE BRAIN. 

had obliterated nearly the whole of the left lobe of the cere- 
bellum. The other parts of the brain were, so far as could 
be perceived, perfectly healthy. 

Extensive haemorrhage may take place in the white sub- 
stance of the cerebrum, and little disturbance of either mo- 
tion or sensibility result. It usually happens, however, that 
the extravasation makes its way to the motor tract, and then 
the symptoms due to lesion of this part of the brain make 
their appearance. Besides the occurrence of local second- 
ary lesions, the immediate result of the presence of a foreign 
body in the cerebral tissue, there are others, which are due 
to the interruption of the normal brain-functions, which 
haemorrhage so generally induces. Thus, atrophy of the 
cerebral structure may result, as has been pointed out by 
Cotard 1 and others, or the degeneration may extend to the 
spinal cord, as so well shown by Bouchard. 3 In this latter 
event the process does not begin till about the end of the 
fourth or fifth month. 

Treatment. — The means of treatment in cerebral haemor- 
rhage are, first, those which are applicable to the prodro- 
matic stage, with a view of preventing any lesion ; second, 
those proper daring the seizure ; and, third, those which are 
to be directed against the consequences of an attack. 

It often happens that an attack may be prevented, even 
where the threatenings are very decided. The condition of 
the brain is such that the indications are to ]essen the ten- 
sion of the blood as much as possible. As I have already 
remarked, under the head of cerebral congestion, the bro- 
mides of potassium and sodium are peculiarly efficacious in 
accomplishing this end. Lately, in consequence of the in- 
vestigations of Dr. S. "Weir Mitchell, of Philadelphia, I have 
made much use of the bromide of lithium in cerebral con- 
gestion with or without a tendency to haemorrhage, and 

1 Etude sur l'Atrophie Partielle du Cerveau, Paris, 1868. 

2 Des Degenerations Secondaires de la Moelle Epiniere, Archiv. Gen. do 
Medecine, 1866. Also, Hun's translation, American Journal of Insanity, 1869. 



CEREBRAL HEMORRHAGE. 107 

have had reason to prefer it to either the potassium or 
sodium salt. One feature of its action, which renders it 
especially useful in such cases as those now under notice, is 
the short interval which elapses between its administration 
and the effect. I am very sure I have given it successfully 
in several cases in which the other bromides would not have 
acted so happily. In one of these, a gentleman from the 
South, who had already had an attack, and who was in con- 
sequence hemiplegic, was relieved of his vertigo, headache, 
numbness, and thickness of speech, by one dose of thirty 
grains, in less than half an hour. The oxide of zinc may 
also be given with advantage. 

The bowels, if costive, should be opened by a brisk 
purgative ; the stomach, if overloaded, should be emptied 
by an emetic, during the action of which warm water should 
be freely drunk so as to avoid, as far as possible, all strain- 
ing ; muscular exertion should be avoided, the head should 
be kept cool and well elevated, and the mind in a state of 
the utmost tranquillity. 

During an attack, and throughout the whole period of 
reparation of damages, the less that is done in the vast ma- 
jority of cases the better. The question of the propriety of 
bloodletting will generally even yet arise, but should in 
nearly every case be decided in the negative. I say nearly, 
for I know of but one possible form of attack in which it 
can by any possibility not only not be useful, but fail to 
do harm ; and that is in a strong, plethoric person, with a 
full, bounding pulse, in whom, from the gradual develop- 
ment of the symptoms, we have reason to suspect that the 
haemorrhage is still going on. In such a case, six or eight 
ounces of blood may be taken from the arm. But in a case 
of cerebral haemorrhage attended by coma and the ordinary 
symptoms of the apoplectic condition, there is nothing to be 
done in the way of medication, which can afford the slight- 
est prospect of relief. It is true, a patient thus situated may 
recover if his attack is not of the severest kind, but it is not 



108 DISEASES OF THE BRAIN. 

through any medicines we give him. Correct views relative 
to this point are far from being prevalent, and can only be 
established by regard being paid to the morbid anatomy and 
pathology of the subject. 

A clot in the brain is, to all intents and purposes, a for- 
eign body, and both it and the walls of the cavity must un- 
dergo certain fixed and definite changes. In order that these 
changes may go on with the utmost possible regularity and 
certainty, all the powers of the system are requisite. The 
processes are not morbid ; on the contrary, they are in the 
highest degree conservative. To take blood from a body 
which is striving by all its agencies to repair an injury, is to 
deprive it of a portion of its strength without in the slight- 
est degree accelerating the actions at the seat of the lesion. 
As Trousseau J remarks, no physician ever thinks of bleed- 
ing for an extravasation of blood under the skin, for he 
knows how perfectly absurd such a practice would be ; and 
yet, except as regards location, there is no difference between 
it and the cerebral clot. A prize-fighter, for instance, re- 
ceives a blow in the face which ruptures a blood-vessel and 
gives him a "black eye." He has an extravasation of blood 
into the cellular tissue. What would be thought of the phy- 
sician who would recommend bloodletting from the arm 
with a view of causing the absorption of the clot? The 
prize-fighter has found out by experience that he can open 
the skin with a knife and let the blood out. The practice 
is excellent, and would be admirable for the brain also, were 
this organ of no more vital importance than the skin of the 
face. I have never bled a patient for cerebral haemorrhage 
since 1849, and I am very sure that I have had no reason to 
regret the abandonment of the practice. 

It is a common practice for purgatives to be given, and 
even so conservative a practitioner as Dr. J. Hughlings Jack- 
son 2 puts " two drops of croton oil on the tongue," why, he 

1 Lectures on Clinical Medicine, Bazire's Translation, Part L, p. 10. 

2 Reynolds's System of Medicine, vol. ii., Article Apoplexy and Cerebral 
Haemorrhage, p. 541. 



CEREBRAL HEMORRHAGE. 109 

does not state, and certainly the practice is in direct antag- 
onism not only with his assertion that " the chief thing is to 
keep the patient quiet," but with the general tenor of his 
theory of treatment. I have seen great annoyance and an 
aggravation of the symptoms from the indiscriminate ad- 
ministration of croton oil. It is only, in my opinion, admis- 
sible when there is obstinate constipation, and when after 
three or four days the bowels have not been moved. 

And then as regards iodide of potassium. There seems 
to be an idea prevalent that this substance exerts a powerful 
influence in causing the more rapid absorption of the ex- 
travasated blood, and hence it is frequently administered in 
large and frequently-repeated doses. I have often seen pa- 
tients, at as early a period as possible, while still in a state 
of profound coma, dosed with the iodide of potassium to the 
extent of five grains every hour, with the object of causing 
the immediate absorption of the extravasated blood. That 
such a result is impossible no one acquainted with the mor- 
bid anatomy and the pathology of the subject will deny. 

In fact, there is nothing to be done beyond keeping the 
patient perfectly quiet, with the head well elevated, and in 
a room, when possible, with a temperature of about 60° and 
thoroughly ventilated. Indications should be met as they 
arise. The bowels, if not moved naturally every day, may 
be emptied by an enema of warm water ; the urine, if not 
passed by the patient, should be drawn off with the cathe- 
ter ; the strength, if feeble, as indicated by the pulse, should 
be kept up by the cautious use of stimulants ; and, if the 
patient is restless and does not sleep well, some one of the 
bromides should be administered. 

The food should be of the most nutritious character, so 
as to be small in quantity, and should be taken frequently, 
day and night. Beef-tea, or the extract of beef, made ac- 
cording to Liebig's formula, supplies every indication. 

If symptoms of inflammation make their appearance, 
cold applications may be made to the scalp, or a blister 



HO DISEASES OF THE BRAIN. 

may be applied to the nape of the neck. Blisters or mus- 
tard plasters to the wrists or ankles are absurd. 

Nothing should be done for the relief of the paralysis 
till all signs of irritation of the brain have disappeared, and 
the patient begins to feel the restraint of confinement, and 
to make efforts to move his paralyzed limbs. These evi- 
dences of improvement generally begin soon after the eighth 
day. In about two weeks, therefore, it will be proper, in 
the majority of cases, to take active measures to restore the 
power of motion, and to prevent those contractions which 
tend to make a restoration much more difficult. The agents 
to be employed are passive motion, strychnia, phosphorus, 
and electricity. The first is accomplished by flexing and ex- 
tending the joints of the affected limbs, by friction, and by 
kneading the muscles with the fingers. These movements 
should be performed every day for five or ten minutes at a 
time. The patient should likewise be encouraged to move 
the limbs by his own volition as often as possible short of 
causing fatigue. Strychnia should be given in doses of the 
one-twenty-fourth of a grain three times a day, or, prefer- 
ably, by subcutaneous injection, in somewhat smaller doses, 
once a day. In old cases of hemiplegia, the effects of strych- 
nia thus administered are often well marked, and are exhib- 
ited when administration by the stomach has failed to pro- 
duce a beneficial result. This is seen in the following brief 
abstract of thirteen cases which will serve as types of nu- 
merous others which have occurred in my private practice. 

Case I. — H. A., aged fifty; male; right hemiplegia. 
Came under treatment January, 1865 ; strychnia ineffectual 
by the stomach; thirteen injections, of from one-thirty- 
second to one-twenty-fourth grain ; much improved. 

Case II. — J. S. ; forty-two ; male ; left hemiplegia. Feb- 
ruary, 1865 ; thirteen injections ; much improved. 

Case III. — S. T. ; sixty ; female ; right hemiplegia. Feb- 
ruary, 1865 ; strychnia ineffectual by the stomach ; nine 
injections ; much improved, 



CEREBRAL HEMORRHAGE. HI 

Case IY. — I. S. ; sixty ; female ; right hemiplegia. April, 
1865 ; five injections ; much improved. 

Case V. — 1L T. ; fifty-two ; male ; right hemiplegia. 
April, 1865 ; strychnia ineffectual by the stomach ; eleven 
injections; cured. 

Case VI. — O. S. ; sixty-three ; female ; left hemiplegia. 
April 30, 1865 ; secondary contractions; twenty-two injec- 
tions ; no improvement. 

Case VII. — B. R. ; forty-seven ; male ; left hemiplegia. 
June 11, 1865 ; strychnia ineffectual by the stomach ; seven 
injections ; much improved. 

Case VIII. — R. F. ; fifty ; male ; left hemiplegia. June, 
17, 1865 ; strychnia ineffectual by the stomach ; eight in- 
jections; cured. 

Case IX. — T. TV". ; forty-eight ; male ; left hemiplegia, 
September 5, 1865 ; eight injections ; much improved. 

Case X. — T. S. ; forty-nine ; male ; left hemiplegia. 
September 7, 1865 ; secondary contractions ; five injections ; 
no improvement. 

Case XI. — J. J. ; fifty-seven ; male ; left hemiplegia. 
September 11, 1865 ; secondary contractions ; no improve- 
ment. 

Case XII. — J. MV. ; fifty-two ; male ; right hemiplegia, 
affecting arm only, at the time treatment was begun. Sep- 
tember 27, 1865 ; strychnia ineffectual internally ; six injec- 
tions; cured. 

Case XIII. — YT. M. ; forty-five ; male ; left hemiplegia. 
October 19, 1865 ; strychnia ineffectual internally ; seven 
injections; cured. 

Case XIY. — S. M. ; forty-one; male; right hemiplegia. 
June 17, 1867; arm alone affected; strychnia ineffectual 
by the stomach ; twenty injections ; cured. 

Case XY. — M. C. ; forty-four; male; right hemiplegia, 
affecting tongue and face only. July 1, 1867 ; ten injec- 
tions ; so much improved as to be able to talk with fluency. 

Case XYI. — C. C. ; fifty ; male ; right hemiplegia. May 



112 DISEASES OF THE BRAIN. 

4, 1869; strychnia ineffectual by the stomach; thirty-five 
injections ; much improved. 

Dr. Charles Hunter 1 has called attention to the advan- 
tages to be derived from the hypodermic use of strychnia in 
hemiplegia ; and my late clinical assistant, Dr. E. A. Yance, 3 
has adduced several cases to the same effect. Instances in 
support of the views above set forth occur daily in my pri- 
vate practice, and at the New York State Hospital for Dis- 
eases of the Nervous System. I have every reason, there- 
fore, to be convinced of the good results to be derived from 
the practice. 

Phosphorus administered in the form of phosphide of 
zinc, separately or in combination with the extract of nux- 
vomica, according to the formula given on page 58, is also 
a useful remedy. 

But no agent is so valuable in hemiplegia as electricity, 
and amendment almost invariably follows its use, even in 
old cases, in which there are tonic contractions. If the case 
is seen soon after the seizure, the induced current will gen- 
erally be sufficient to produce contractions of the paralyzed 
muscles. The poles, terminated by wet sponges, should be 
applied to the skin covering the muscles, or in some cases to 
the nerves. The current should be strong enough to cause 
slight pain, or, if sensibility is lessened, to produce contrac- 
tion. In old cases attended with atrophy of the muscles, 
and diminished or abolished electro-contractility, the pri- 
mary current may be necessary. It should be applied in such 
a manner as to be interrupted, for contractions are only caused 
when the circuit is closed and opened. As the muscles im- 
prove in size and irritability, the induced current should be 
used. Care should be taken not to fatigue the patient, or 
to cause excessive pain by employing a current of too great 
intensity. 

1 British and Foreign Medico-Chirurgical Review, April, 1868. 
8 Journal op Psychological Medicine, April, 1870. The first thirteen 
cases cited in this work were published in Dr. Vance's paper. 



CEREBRAL HAEMORRHAGE. 113 

As regards the restoration of sensibility, it will gener- 
ally be found to be less difficult than the removal of the 
motor paralysis. The anaesthesia very often disappears or 
becomes much less spontaneously, and it does so from the cen- 
tre to the periphery ; that is, if there be anaesthesia of the 
leg, the sensibility returns in the upper part first, and subse- 
quently in the lower part. The treatment consists mainly 
in the use of the electric wire-brush, which should be passed 
gently over the skin previously made dry. The other pole 
consists of a wet sponge. Either the induced or primary 
current may be used. If the latter, however, be employed, 
the wire-brush should constitute the positive pole. 

I have frequently succeeded in curing almost complete 
anaesthesia from cerebral haemorrhage by this treatment 
alone. In recent cases it will almost invariably prove effec- 
tual. Hyperesthesia, if present, may be similarly managed. 1 

1 The subject of the employment of electricity in medicine is too extensive 
to receive more than slight notice in a work like the present. For full details 
in regard to it, the reader is referred to the author's translation of Meyer's 
" Electricity in its Relations to Practical Medicine." New York : D. Appleton 
& Co., 1870. 

8 



CHAPTER IT. 

MENINGEAL HEMORRHAGE. 

By the term meningeal haemorrhage is meant an extrava- 
sation of blood into the subarachnoid space, or between the 
dura mater and arachnoid. 

Symptoms. — The most prominent symptom of meningeal 
hemorrhage is coma, which may appear suddenly, or be pre- 
ceded by premonitory symptoms, such as headache, vertigo, 
and general convulsions. The stupor is usually profound, 
and does not differ from that observed in the severe forms 
of cerebral haemorrhage. The power of motion is generally 
lost throughout the body, and consequently there is no 
hemiplegia. The reason for this is, that the haemorrhage is 
so extensive as to press upon both hemispheres. Reflex and 
automatic movements remain, except when the medulla ob- 
longata is involved, when some of them are abolished. In 
this latter situation death soon takes place from cessation of 
respiratory actions. 

In ordinary cases the patient may pass out of the coma- 
tose condition from the fact of the brain becoming accus- 
tomed to the pressure, and he then may be able to speak, 
and to move his limbs, but his mental and physical faculties 
are greatly enfeebled, and a renewal of the haemorrhage 
again plunges him into a state of coma, from which he may 
again emerge. This sequence may be repeated several times, 
until death at last takes place. Before this termination 
there are vomiting, incontinence of urine and faeces, insen- 
sibility, and occasionally general convulsions. 



MENINGEAL HEMORRHAGE. 115 

It has sometimes happened that meningeal haemor- 
rhage, resulting from an injury of the cranium, has not 
caused any very prominent symptoms for a considerable 
period afterward. A teamster was struck on the head by a 
club in the hands of another man, was stunned for a few 
minutes, then recovered, and went about his business with- 
out complaining of his head. In about twelve hours after- 
ward coma supervened, and he died without being aroused. 
A case is reported by Dr. Gibson, 1 in which a still longer 
period intervened. A man, of about sixty years of age, was 
found one morning, about eight o'clock, seated as if asleep 
at a desk, his arms crossed before him and his head resting 
on them. It was discovered that he was profoundly insen- 
sible. He was sent to the hospital, where he lay comatose, 
breathing stertorously, and paralyzed on the whole of one 
side. At the end of two days he died. On post-mortem 
examination there was found fracture of the left side of the 
cranium, with rupture of the dura mater and middle menin- 
geal artery, from which latter, extensive haemorrhage had 
taken place. It was ascertained that, five days before, he had 
fallen down a stone staircase, was stunned for a few minutes, 
but had soon recovered his senses. Doubtless during the 
whole of the intervening period the bleeding from the rup- 
tured vessel had been going on. 

Causes. — Meningeal haemorrhage is often produced by in- 
juries of the skull, and results from sudden rupture of a 
healthy artery or vein. It may follow blows on the head, 
falls, or injuries with instruments which perforate the crani- 
um, and may or may not be associated with fractures of the 
bones. 

The larger vessels, or the capillaries, may give way from 
being diseased, and consequently unable to resist the ten- 
sion of the blood. Such a condition may be the result of 
the long-continued excessive use of alcoholic liquors, or may 
be due to hepatic disease. 

1 Edinburgh Medical Journal, September, 1870, p. 199. 



116 DISEASES OF THE BRAIN. 

In new-born children, there is sometimes meningeal haem- 
orrhage from the pressure made by the instruments used to 
effect delivery. 

The Prognosis in meningeal haemorrhage is always un- 
favorable, death occurring either during the state of coma 
which first appears, or in some one of the subsequent acces- 
sions. 

Diagnosis. — Meningeal haemorrhage is readily distinguish- 
able from cerebral haemorrhage by the facts that the stupor 
comes on gradually, that there is no hemiplegia, and by the 
remissions which take place when the patient does not die 
at first. 

The Morbid Anatomy and the Pathology call for no ad- 
ditional remarks beyond those already made ; and the Treat- 
ment does not differ from that proper in cerebral haemor- 
rhage. 

HEMATOMA OF THE DURA MATER. 

A peculiar form of meningeal haemorrhage, called haema- 
toma, is met with under the dura mater. The blood is not 
diffused, but is collected in sacs which are formed of false 
membranes, the result of chronic inflammation. These cap- 
sules are flattened ovals in shape, are three or four inches 
in diameter, and half an inch thick. They are usually situ- 
ated at the vertex, and involve both hemispheres. When 
this is the case, the paralysis which results is bilateral. 

Symptoms. — The initial symptoms of haematoma of the 
dura mater are the results of chronic inflammation, and are 
slow in their progress. In many respects they resemble 
those indicative of softening, and consist of weakness of in- 
tellect, vertigo, a dull, circumscribed, persistent pain, and 
more or less tendency to stupor. The power of motion is 
generally diminished on both sides of the body, though oc- 
casionally there is hemiparesis. Paralysis is scarcely ever 
complete. Gradually, through a period extending over sev- 
eral months, the stupor increases, and finally the patient 



MENINGEAL HAEMORRHAGE. 117 

becomes apoplectic. During the whole course of the dis- 
ease the pupils are strongly contracted. The patient dies 
comatose and frequently convulsed. 

Causes. — Early and old age are both predisposing causes, 
the disease being met with mainly in children and very old 
persons. It is frequently seen in the insane, and may prob- 
ably result from rheumatism, the excessive use of alcoholic 
liquors, and fevers. The cause is sometimes to be found in 
wounds or injuries of the skull. 

Diagnosis. — It is doubtful if haematoma of the dura mater 
can be definitely recognized either in the stage of inflamma- 
tion or that of haemorrhage. Legendre * states that, in chil- 
dren, the most important diagnostic mark is the permanent 
contraction of the hands and feet, which is so generally pres- 
ent ; but this symptom is certainly met with in other 
cerebral disorders, and may even result from reflex irri- 
tations. The diagnosis is rendered still more difficult by the 
fact that the disease under consideration is often associated 
with other cerebral disorders which mask or modify its symp- 
toms. The absence of fever, the contraction of the pupils, 
the slowness and irregularity of the pulse, the facts that 
there are no vomitings and no general convulsions, that the 
nerves distributed to the several parts of the face ' are not 
paralyzed, that there are constant and very severe headache, 
and a gradually increasing tendency to stupor, are, accord- 
ing to Jaccoud, 2 sufficient to indicate the presence of hgema- 
toma of the dura mater. I am of the opinion that they only 
enable us to give a guess which has some basis in proba- 
bility, for I have several times witnessed exactly such a con- 
dition as that described, and after death found other morbid 
conditions than hsematoma. 

The Prognosis is unfavorable, death resulting sooner or 
later, according to the extent of the disease and the natural 
powers of the patient. 

1 Recherches sur quelques Maladies de l'Enfance, Paris, 1846. 

2 Traite de Pathologie Interne, tome i. s Paris, 1870. 



118 DISEASES OP THE BRAIN. 

Morbid Anatomy and Pathology. — The first stage of hema- 
toma of the dura mater is characterized by the formation of 
the false membranes, to which allusion has already been 
made. These membranes are found on the internal surface 
of the dura mater, and are reticulated, presenting somewhat 
the appearance of spiders' webs. They generally have their 
seat near the sagittal suture, and extend to both hemispheres, 
being only separated from them by the arachnoid and pia 
mater. Yirchow, who has studied their formation with 
greater care than any other observer, has found more than 
twenty layers of them, one on top of the other, and traversed 
by numerous blood-vessels. 

Owing to this great vascularity, to the extreme tenuity 
of the vessels, and to the absence of any perivascular sup- 
port, hemorrhage is liable to occur, and the several lamellae 
thus constitute a sac into which the blood may be poured. 
This, pressing upon the cerebrum below, and constantly 
being enlarged by subsequent hemorrhages, gives rise to the 
symptoms observed during life. The vessels may be more 
liable to rupture from the existence of atheromatous degen- 
eration of their coats. 

Treatment. — This requires no amplification at my hands, 
as I do not believe in the efficacy of any means in curing 
the affection. All that can be done is to palliate the more 
violent symptoms, such as the headache and feebleness of 
mind and body, by anodynes and stimulants, and of these, 
morphia administered hypodermically, and alcohol in some 
one or other of its numerous forms, are to be preferred. 
Bloodletting and blistering are worse than useless. 



CHAPTEE Y. 

PARTIAL CEREBRAL ANEMIA FROM OBLITERATION OF CERE- 
BRAL ARTERIES. 

One or more arteries of the brain may be obliterated and 
anaemia of those parts supplied by it produced through the 
action either of thrombosis or embolism. 

THROMBOSIS. 

By thrombosis is understood a condition in which a blood- 
vessel undergoes narrowing of its calibre by the deposition 
of fibrine from the blood on its internal surface. The clot 
thus formed is called a thrombus. 

Symptoms. — The phenomena observed in consequence of 
the formation of a thrombus in a cerebral artery are grad- 
ual in their development, and are often interrupted by stages 
of apparent improvement. Headache, as in so many other 
affections of the brain, is a prominent symptom and is almost 
constantly present. It is rarely diffused over the whole 
head, but occupies a place having a close relation in situa- 
tion with the seat of the disease. It is rarely of a very ag- 
gravated character, and is remarkable rather for its persist- 
ency than its severity. In several cases which have come 
under my notice, the pupil of the eye of the affected side 
was dilated from the first, and there were ptosis and strabis- 
mus, showing that the third nerve was involved. 

At a very early period in the progress of the disease it is 
not uncommon to meet with marked difficulties in the fac- 
ulty of speech, and these not only relate to the articulation, 



120 DISEASES OF THE BRAIN. 

but to the memory of words. As regards the first-mentioned 
form, there may be restraint in the movements of the tongue, 
the lips, or both, or there may be a loss of coordinating pow- 
er in the muscles concerned in speech without any actual 
paralysis. Special inconvenience is, therefore, experienced 
when attempts are made to pronounce words in which the 
labial and lingual letters are prominent. The gutturals in 
such cases are enunciated without difficulty. In the other 
form in which the memory of words is impaired, the patient 
is constantly at a loss for language with which to express 
his ideas ; and, though the proper words may be supplied to 
him, he almost immediately forgets them again. The full 
consideration of this interesting subject will be found under 
the head of aphasia. 

Yertigo, though generally present, is not usually severe, 
at least in the early stages. 

The incipient symptoms of paralysis soon make their ap- 
pearance in the majority of cases, and, though there is a grad- 
ual advance in the loss of power, there are periods of almost 
entire remission. Thus the leg, or the arm, or the face, may 
be the original seat of the paralysis, and eventually the 
whole of one side be involved. In a case of thrombosis in a 
gentleman now under my charge, the paralysis was at first 
limited to the muscles supplied by the ulnar nerve and those 
concerned in deglutition. For one period of five days after 
I first saw him, there was an entire remission of his symp- 
toms, and he could move his hand and swallow as well as 
ever, but gradually the power was again lost, and other mus- 
cles became involved. At the present time (December 1, 
1870), he is almost entirely hemiplegic. 

Sensibility is also generally abolished or impaired on the 
paralyzed side, and thus the various forms of numbness, 
such as tingling, formication, etc., are present. 

The mental symptoms are usually apparent from the first, 
but may be altogether absent or else so slightly shown as not 
to attract attention. The memory is impaired, not only as 



PARTIAL CEREBRAL ANAEMIA, ETC. 121 

regards words to which reference has already been made, 
but also events and circumstances, especially those of recent 
date. The names of persons and things are likewise readily 
forgotten. In the case of a gentleman whom I saw in con- 
sultation, and in whom I diagnosticated thrombosis, there 
was left hemiplegia involving both arm and leg, but not the 
foot, which had begun in the fingers and gradually extended. 
There was no special difficulty of speech except as regarded 
the recollection of words, but the memory was wonderfully 
impaired in every other respect. I entered his room upon 
one occasion just as the servant was carrying out a tray with 
the remains of his breakfast. Not three minutes had elapsed 
since he had eaten, and yet he assured me he had tasted 
nothing since the day before. The loss of memory was the 
first symptom observed in this case. Soon afterward he be- 
gan to improve, and he is now, after fifteen months, free 
from paralysis, and with his memory almost as good as ever. 
The loss of memory in such cases seems to be due in the 
main to the fact that the power of concentrating the atten- 
tion upon any subject is very much diminished. There is 
likewise an indisposition to exert the powers of the mind or 
body, and thus the patient tends to pass into a condition of 
apathy. Somnolence is a frequent symptom. 

During the first stage of thrombosis, before the artery is 
entirely closed, amendment, and even complete recovery, 
may take place. The remissions in the symptoms already 
referred to are due to the establishment of the collateral 
circulation, and this may become so complete as to eventu- 
ate in cure. It must be confessed, however, that the condi- 
tion of anaemia to which the foregoing symptoms are due, 
in the great majority of cases ends in softening — a sub- 
ject which will presently be considered as one of the conse- 
quences of thrombosis and other morbid states. 

Causes. — Thrombosis may result from atheroma of the 
artery, by reason of which its elasticity is diminished and 
the smoothness of its linino* membrane destroved. Both 



122 DISEASES OF THE BRAIN. 

these conditions retard the course of the blood, and favor 
the deposition of fibrine on the internal periphery. The 
walls of the vessels may be healthy, and a thrombus may 
then be formed through a weak action of the heart — the 
result of fatty degeneration or other cause impairing its 
strength. 

The predisposing causes are, age — the disease being rare 
in persons under fifty years — the excessive use of alcoholic 
liquors or of fatty or starchy articles of food, with insuffi- 
cient exercise, and perhaps inordinate mental exertion, 
which, by impairing the tone of the arteries, in consequence 
of their constant overdistention, diminishes their elasticity, 
and may consequently lead to the formation of thrombi. 

Diagnosis. — Thrombosis is distinguished from cerebral 
congestion by the facts that the mental and other symptoms 
are more profound in character, and that the patient has 
generally passed the prime of life. The existence of paraly- 
sis among the early symptoms will likewise tend to the 
formation of a correct opinion. From cerebral haemorrhage 
it is diagnosticated by the circumstance of its gradual devel- 
opment ; from encephalitis by the absence of fever and the 
more chronic nature of the disease ; and from embolism by 
its slow progress and the impossibility of defining the exact 
period of its beginning. 

Prognosis. — The prognosis in cerebral thrombosis is unfa- 
vorable, for the reason that, although the morbid process 
may advance slowly, and may even be spontaneously arrest- 
ed in its course before the artery is closed, the tendency to 
complete obliteration is always great, and the chance of suffi- 
cient circulation being carried on by the collateral vessels is 
very remote. The disposition to softening, therefore, always 
exists, and generally cannot be overcome. The inadequacy 
of any medical treatment to control the action going on 
within the artery, or to aid to any great extent in the devel- 
opment of the collateral circulation, is also an element in 
forming an opinion as to the ultimate result. 



PARTIAL CEREBRAL ANAEMIA, ETC. 123 

Morbid Anatomy and Pathology. — Although Virchow 1 was 
the first to write distinctly in regard to the nature of throm- 
bosis, the condition was recognized long before his researches 
were made, and cases of clots plugging up the vessels are to 
be found detailed by many of the older medical authors, 
among whom Abercrombie, Carswell, and Cruveilhier, may 
be mentioned. Since Yirchow began his observations in this 
direction, many instances have been recorded and a large 
number of memoirs have been issued upon the subject. An 
interesting case was related by Dr. Packard, 2 of Philadelphia, 
at a meeting of the Pathological Society of that city held in 
December, 1859. The patient, who had been under the care 
of Dr. Heller, was a bachelor, fifty-one years of age. At six 
o'clock in the morning, at the beginning of February, he was 
seized with paralysis of the left arm and leg. He was a man 
of very regular habits, and of fanatical love for every thing 
instructive, and an accomplished scholar in botany, geogra- 
phy, and languages. The paralysis was soon relieved, and he 
was able, four weeks afterward, to go out again and to use 
his arm tolerably well. About the middle of March, in con- 
sequence of a fatiguing walk the previous evening, and an 
attack of diarrhoea during the night, complete paralysis re- 
turned. From this he never recovered, but yet did not die 
till the December following. Previous to this termination 
he had confusion of ideas and delirium. Upon post-mor- 
tem examination, among other morbid changes, a cavity in 
the right corpus striatum was found, and this was surround- 
ed by a spot of softening of the cerebral substance as large 
as an egg. The basilar artery was completely blocked up 
with clots, as was also the right carotid. These vessels 
were atheromatous, and the basilar artery was aneurismally 
dilated. The clots had all the appearance of being old. 

Dr. Dickinson 8 has brought forward five cases of occlu- 

1 Froriep's Neue Notizen, 1846. Heft xxxvii. 

2 North American Medico-Chirurgical Review, vol. iv., 1860, p. 306. 

8 On the Formation of Coagulae in the Cerebral Arteries. St. George's 
Hospital Reports, vol. i., 1866, p. 257. 



124 DISEASES OF THE BRAIN. 

sion of arteries, several of which I am disposed to think 
were of embolism, instead of thrombosis, as he considers 
them to be. Dr. Dickinson nowhere alludes to Yirchow's 
investigations, but gives the whole credit of the discovery 
of the relation between emboli and the formation of con- 
cretions in the heart to Dr. Kirkes. The conclusions which 
he draws from his cases are by no means original, although 
he evidently so regards them. 

The questions to be considered in connection with the 
morbid anatomy of thrombosis relate to the condition of the 
artery, the nature of the clot, and the changes which take 
place in those parts of the brain which are deprived of their 
due supply of blood. 

The affections of the artery, being similar to those which 
render it liable to rupture, need not be dwelt upon at any 
length here, as they have already been noticed under the 
head of the morbid anatomy of cerebral haemorrhage. Suf- 
fice it, therefore, to say that endarteritis and atheromatous 
degeneration are the diseased states generally met with. 

The clot which closes the vessel is, in the beginning, 
coagulated blood, and hence consists of fibrine and white and 
red blood-corpuscles. The elements, with the exception of 
the fibrine, are gradually disintegrated and washed away by 
the current of blood which continues to flow through the 
vessel before it is entirely closed, and therefore the layers 
nearest the arterial wall consist almost entirely of fibrine 
and the one nearest the centre of the vessel, which is the 
latest formed, of fibrine and corpuscles. An examination of 
such a clot with the microscope shows that the above-men- 
tioned morphological elements are found in its centre, more 
or less changed, however, according to the age of the forma- 
tion. A thrombus may undergo purulent softening and dis- 
integration to such an extent as to result in its breaking up 
into fragments, which may lodge in the vessel or its branches 
farther on, and thus constitute emboli. 

The region of the brain to which the artery undergoing 



PARTIAL CEREBRAL ANAEMIA, ETC. 125 

occlusion is distributed is, of course, deprived to some extent 
of its blood, and hence presents at first an appearance of 
anaemia. And this is not prevented by the increase of the 
collateral circulation, which is never sufficiently vigorous to 
compensate entirely for the loss by the primary vessel. 

Microscopic examination shows the capillaries to be 
smaller and less numerous than in the normal condition, 
though there is not any palpable softening. 

But after the artery is entirely closed a change ensues. 
The anaemic portion of the brain becomes red or pink, and 
this color is deepest on the borders, owing to the collateral 
circulation which is now fully established. This stage has 
been called red softening, but I am disposed to think the 
designation erroneous, and that it is liable to convey false 
ideas of the pathology. For it is perfectly possible at this 
time for the anaemic portion of the brain to be restored 
through the activity of the collateral circulation, with the 
effect of causing a cessation of the symptoms. If, however, 
this should be insufficient to provide for the due nutrition 
of the affected region, softening takes place, and a cure be- 
comes almost impossible. 

Obliteration of a cerebral artery does not always produce 
notable symptoms. For these to follow, the morbid process 
must be set up in a vessel with but few and small collateral 
branches. Thus, if the internal carotid be obstructed, the 
circulation is carried on through the circle of Willis by the 
supply of blood derived from the vertebrals. The basilar 
artery might also be occluded at any limited region between 
a pair of transverse arteries, and the circulation still kept up 
by the carotids on the one side, and the vertebrals on the 
other. But any closure so as to involve one or more of the 
transverse arteries must lead to anaemia, and subsequent soft- 
ening of the pons Yarolii. Thus, in a case reported by Ben- 
nett, 1 in which there had been vertigo and other head-symp- 

1 Clinical Lectures on the Principles and Practice of Medicine, third edition, 
Edinburgh, 1850, p. 3*70 



126 DISEASES OF THE BRAIN. 

toins for several years, and in which paralysis of the left 
arm, without loss of consciousness, had suddenly supervened, 
the basilar artery was found entirely obliterated throughout 
its entire extent, all the transverse arteries were of course 
closed, and the supply of blood to the pons cut off on both 
sides of the mesial line. 

A very interesting memoir by Hayem 1 alleges occlusion 
of the basilar artery by thrombus to be a cause of sudden 
death. In all of his cases, four in number, the artery was 
closed throughout a great part of its extent, as the result of 
extensive arteritis and the formation of dense clots. In the 
fourth case there was also thrombosis of the left middle 
cerebral artery, with difficulty of speech. 

The vessels the closure of which produces the greatest 
disturbance of function are the anterior, middle, and poste- 
rior cerebral which supply the hemispheres, the corpus stria- 
tum, optic thalamus, and other important ganglia. Be- 
sides the effect due directly to the ansemia, more or less dis- 
turbance results from the congestion posterior to the clot, 
and the consequent effusion of serum. 

Treatment. — A knowledge of the morbid anatomy and 
pathology of cerebral thrombosis must satisfy us of the in- 
sufficiency of any medical treatment to cause the absorption 
of the clot obliterating the channel of the artery. Yet I 
have several times heard it gravely proposed to administer 
the iodide of potassium, with the view of accomplishing this 
object. As regards facilitating the establishment of the col- 
lateral circulation, nature will generally take care of this, 
and may even so far overdo it as to cause haemorrhage from 
the rupture of vessels not accustomed to the increased tension 
of the blood. It may therefore be necessary, in this latter 
condition of excessive action, to give the bromide of potas- 
sium in large doses. Should the circulation be feeble, the 
skin cold, and the patient disposed to somnolence, we 

1 Sur la Thrombose par Arterite du Tronc Basilaire, comme cause du mort 
rapide, Archives de Physiologie Normale et Pathologique, 1868, p. 270. 



PARTIAL CEREBRAL ANiEMIA, ETC. 127 

have reason to suppose that the collateral circulation is not 
being formed with sufficient rapidity, and therefore the pa- 
tient should be kept with the head low, brandy or other 
spirituous liquors administered, and the body wrapped up 
in warm blankets. 

For some time after the successful establishment of the 
collateral circulation there is more or less feebleness of mind 
and body. For this condition strychnia and phosphorus are 
especially applicable, and may be administered according to 
the formulas recommended under the heads of cerebral con- 
gestion and cerebral haemorrhage. Electricity is almost 
always useful. 

EMBOLISM. 

Embolism is the term applied by Yirchow to the closure 
of an artery by an embolus, which is a clot formed in some 
other part of the body and transported by the current of the 
blood to the vessel which it occludes. It therefore differs 
from thrombosis in the facts that it is not associated with 
previous disease of the artery, and that the closure of the 
vessel is sudden. 

Symptoms. — There are no premonitory symptoms. As in 
cerebral haemorrhage, the patient may be sitting perfectly 
quiet when he suddenly loses consciousness and falls to the 
ground, comatose. As the stupor passes off, he finds that he 
is paralyzed upon the side of the body opposite to the seat 
of the lesion. 

Or there may be no coma, but merely slight confusion 
of ideas for a moment or two with sudden accession of paral- 
ysis on a limited portion of one side, involving only the arm 
or leg. Or, again, the face or the tongue may be the only 
parts paralyzed. Or there may be no paralysis anywhere, 
and no mental symptoms except as regards the faculty of 
language, which is entirely or partially lost. 

Sometimes there are ocular troubles, such as ptosis, stra- 
bismus, or blindness. 



128 DISEASES OF THE BRAIN. 

Experience shows that the embolus, for reasons which 
will be given hereafter, generally lodges in the left middle 
cerebral artery, and that with the right hemiplegia — if there 
is paralysis at all — there is often aberration of the faculty 
of speech. 

The symptoms of mental derangement, with the excep- 
tion of the coma of severe attacks, are not ordinarily promi- 
nent. I have, however, witnessed several cases in which 
they formed a very striking feature of the case. In one of 
these, in which the clinical history of the patient disclosed 
the preexistence of several attacks of acute articular rheu- 
matism, with subsequent endocarditis and mitral and aortic 
valvular lesions, there were hallucinations and delusions in 
addition to the complete paralysis of the left side. All these 
phenomena entirely disappeared within thirty-six hours. 
This case is one of the few in my experience in which the 
embolus had occluded an artery on the right side of the 
brain. 

In another, likewise with valvular disease of the left 
side of the heart, there was delirium from the first, and this 
disappeared as the collateral circulation was established. 

Erlenmeyer has written very excellently of cerebral em- 
bolism, but is, I think, incorrect in some points of his symp- 
tomatology. He states the ordinary phenomena of an at- 
tack to be as follows : 

There are no prodromata ; sudden loss of consciousness, 
with paralysis of several parts of the body. The facial, the 
hypoglossal, and the nerves of the extremities, are always 
more or less affected. Sensibility is abolished in the con- 
junctiva, but is retained in the cornea. The pupils remain 
sensitive, and are neither contracted nor dilated, neither are 
there symptoms of concussion or compression. There are no 
vomitings and no contractions. The pulse is weak and 
small, and the temperature rather below the normal stand- 
ard. Occasionally there are epileptiform convulsions. Psy- 
chical troubles do not ordinarily appear till the collateral 



PARTIAL CEREBRAL ANEMIA, ETC. 129 

circulation becomes active, and local hyperemia is thus in- 
duced. 

The principal exception I have to make to the foregoing 
sequence of symptoms is the too absolute assertion of the 
paralysis of the facial, hypoglossal, and other nerves. I 
have seen several cases in which there was no paralysis to 
be detected in any part of the body by the most careful ex- 
amination, and several others are on record. In one very 
interesting instance, occurring in a lady who had had re- 
peated attacks of acute rheumatism, and who had at the 
time marked aortic insufficiency, headache and vertigo sud- 
denly occurred while she was conversing with a friend, and 
her speech was cut short with as much suddenness as though 
she had been shot. There was no paralysis of the tongue, 
but all idea of language was abolished. Within forty-eight 
hours she recovered entirely the faculty of speech. In an- 
other, that of a gentleman with a similar clinical history, 
headache, vertigo, confusion of ideas, and amnesic aphasia, 
suddenly supervened. That both these were cases of embo- 
lism can scarcely, I think, be doubted. 

And then, as regards the state of the pupils, my experi- 
ence does not coincide with that of Erlenmeyer, for I have 
frequently found either dilatation or contraction of both 
pupils, or dilatation of one and contraction of the other. 

In examining a case of recent embolism, the ophthalmo- 
scope should always be used to view the fundus of the eye, 
and even in old cases valuable signs will often be obtained. 
The middle cerebral artery, the ordinary seat of embolus, 
arises from the internal carotid after the anterior cerebral 
and ophthalmic have been given off. Occlusion of its chan- 
nel must, of course, throw an increased amount of blood into 
these last-named arteries, and, as the arteria centralis retinae 
is derived from the ophthalmic, it and its branches become 
enlarged. The ophthalmoscope will enable us to discover 
the congestion thus produced, and will often be the means 
of helping us to determine, in the absence of paralysis, 
9 



130 DISEASES OF THE BRAIN. 

which side of the brain is the seat of the lesion. In older 
cases we will frequently find retinal congestion. 

The following case I quote not only as being the first of 
which I have any knowledge in which the ophthalmoscope 
was used in a case of cerebral embolism, but as being inter- 
esting from the fact that the embolus was on the right side. 
It is reported as 

Cerebral Embolism following Valvular Disease of the 
Heart. — John Turnbull, aged seventeen, was admitted into 
the Hull General Infirmary, on April 25, 1 867. He was tall, 
much wasted, and had a suffering expression, and converg- 
ing strabismus of the left eye, the mouth being drawn very 
slightly toward the left side. Pulse 70, very thrilling in 
character, and a large coarse systolic murmur near the left 
nipple. He was perfectly sensible, complained of severe 
frontal headache, with confusion of vision, and stated that 
he had been in much the same condition for seven weeks, 
his illness beginning spontaneously with headache and vom- 
iting, unaccompanied by loss of consciousness or convulsions. 
He had had an attack of acute rheumatism in the previous 
summer. He was ordered gr. iij of blue-pill and gr. ij of 
extract of henbane in a pill, and a draught of acetate of am- 
monia, three times a day, and spirit-lotion to the head. 
" No marked alteration in his condition, except progressive 
debility, took place till May 2d, when he complained of in- 
creased headache and dimness of vision, and being unable 
to expectorate, from excessive weakness, death from bron- 
chial obstruction threatened. With the aid of some cham- 
pagne, he rallied in about twenty-four hours, and at the end 
of a week was much improved, having a clean tongue and 
good appetite, but the headache, strabismus, and deviation 
of the tongue to the left, remained. On May 16th it was 
noticed that these symptoms had passed off, with the excep- 
tion of the last mentioned. He was ordered a mineral-acid 
mixture. 

" A week later, as he still complained of some dimness 



PARTIAL CEREBRAL ANEMIA, ETC. 131 

of sight, he was examined with the ophthalmoscope. The 
retinal vessels were fonnd much enlarged, and the veins very 
tortuous ; the optic nerve-entrance of an intense red color, 
not being distinguishable from the surrounding parts except 
by the entrance of the vessels, the redness being chiefly due 
to a number of very fine vessels radiating from the centre. 
There was no morbid effusion in any part. He could spell 
easily from ISTo. 15 of Jaeger's test-types (being unable to 
read and write). He was again examined at the end of 
another week, when the optic nerve-entrance was observed 
to be paler in color, so that its circumference could be dis- 
tinguished, but still much injected, and the vessels nearly as 
large and tortuous as before ; sight was apparently perfect. 
He was discharged convalescent. 

" The peculiar form of paralysis in this case denoted 
some morbid condition within the cranium, which appeared 
to have its most easy and natural explanation in cerebral 
embolism, an opinion further supported by the perfect re- 
covery of the patient. The case received much additional 
interest from the information afforded by the ophthalmo- 
scope, for one may fairly believe that the intense congestion 
of the retinas denoted a similar condition of the brain, per- 
haps a state of reaction after the circulation had been re- 
established through collateral channels." ' 

Causes. — The most common first step in the causation of 
cerebral embolism is acute articular rheumatism, which, by 
inducing acute endocarditis, leads to the formation of em- 
boli on the valves of the heart and other parts of the en- 
dangium. Aneurisms of the aorta or other large artery, 
resulting in the coagulation of the blood in the aneurismal 
sacs, may likewise induce it, by a portion of the clot being 
washed off by the current. Esmarch 2 details a case in 
which, while an examination was being made of an aneu- 

1 British Medical Journal, 1867, also Quarterly Journal of Psychologi- 
cal Medicine, January, 1868, p. 118. 

2 Archiv fur PathoL Anatomie und Physiologie, B. xi., Heft. 5, 1857. 



132 DISEASES OF THE BRAIN. 

rism of the carotid, the patient suddenly fell back in an 
apoplectic stupor. The whole right side was at once para- 
lyzed, the facial muscles on the left were convulsed, and 
four days afterward death ensued. Post-mortem examina- 
tion showed that the left internal carotid, the middle cere- 
bral, and the ophthalmic, were completely closed by coagula, 
which were identical in structure and appearance with the 
clot in the aneurismal sac. 

Emboli may also originate in the lungs, and, entering 
the left auricle through the pulmonary veins, finally lodge 
in a cerebral artery. 

Age appears to exercise no influence over the formation 
of emboli, but men are much more commonly the subjects 
than women, for the reason, undoubtedly, that they are 
more liable to attacks of rheumatism. 

Of thirty-seven cases under my care, either alone or in 
consultation, in which I had reason to diagnosticate cerebral 
embolism, there was organic disease of the heart in all but 
one. Three of the cases were over sixty years of age ; four 
between fifty and sixty ; seven between forty and fifty ; 
thirteen between thirty and forty; and ten under thirty. 
Twenty-five were males and twelve were females. 

Diagnosis. — From cerebral haemorrhage, embolism may 
be distinguished by the following signs. It occurs without 
relation to age, while haemorrhage is much more frequent 
in persons over forty ; there are no prodromata : the result- 
ant paralysis is generally on the right side, while in haemor- 
rhage there is no such predisposition ; and it is in the great 
majority of cases associated with organic disease of the left 
side of the heart. Care, however, must be taken not to 
overestimate the value of this diagnostic mark, valuable as 
it is. In one case under my charge, in which the symptoms 
pointed strongly to the existence of a cerebral embolus, and 
in which, after death, the left middle cerebral artery was 
found occluded, the heart was perfectly healthy ; and in one 
other, in which cerebral embolus was diagnosticated, and in 



ETC. 133 

which there was mitral regurgitation, extravasation into the 
corpus striatum was discovered to he the cause of death. A 
case has recently been reported by Dr. J. Hughlings Jack- 
son, 1 in which there was cerebral haemorrhage with hemi- 
plegia, together with extensive valvular disease of the heart. 

A patient now in the !New York State Hospital for Dis- 
eases of the ^Nervous System has left hemiplegia, involving 
face, arm, and leg. It has already lasted seven months, al- 
though greatly improved. The hand and arm are much 
contracted. The attack was apparently induced by strong 
muscular exertion being made while in a stooping and con- 
strained position. Most physicians would be disposed to 
agree with my diagnosis, that the case is one of cerebral 
haemorrhage, for the obvious cause of the paroxysm, the 
lesion being on the right side of the brain, the steady im- 
provement and the muscular contractions, all point to ex- 
trasavation of blood instead of embolus. Yet he is under 
twenty years of age, and, before the seizure, had an attack of 
acute rheumatism, with heart-difficulty. He now has aortic 
and mitral regurgitation. Such cases as the above are very 
instructive, and they show us how necessary it is to weigh 
all the facts, and how great is the possibility of making a 
mistake after all. For, although I am inclined to the view 
of haemorrhage, no definite opinion can be given without a 
post-mortem examination. 

Still in a case of partial or complete hemiplegia, with or 
without apoplexy, in which the patient was below the age 
of forty, with the hemiplegia involving the right side, no 
muscular contractions and organic disease of the left side of 
the heart, with or without previous attacks of acute articu- 
lar rheumatism, cerebral embolus may safely be said to 
be the cause of the symptoms. Moreover, the paralysis 
from embolism, if it does not disappear within seventy- 
two hours after the seizure, does not gradually fade away as 
it so frequently does to a great extent in haemorrhage. 

1 British Medical Journal, October 29, 1870, p. 459. 



134 DISEASES OF THE BRAIN. 

The suddenness with which embolism takes place, to 
say nothing of the other points in the clinical history, will 
suffice for the discrimination from thrombosis. 

Prognosis. — The prognosis in cerebral embolism is grave, 
for the reason that the tendency to softening of the anaemic 
cerebral tissue always exists. But, if the patient passes over 
the first four or five days without any aggravation of his 
symptoms, and especially if they be mitigated in violence, 
there is considerable hope of a favorable result. Still, a 
guarded opinion should always be given till all head-symp- 
toms have disappeared. 

Morbid Anatomy and Pathology. — The first rational expla- 
nation of embolism was made by Yirchow, 1 in 1847, who, 
in his paper on acute inflammation of the arteries, distinctly 
explained the manner in which the vessels were occluded by 
clots transported in the blood from distant parts of the body, 
and who associated these coagula with valvular disease of the 
heart. In two of the cases cited by him in which arteries 
were found closed by such clots, the valves of the heart were 
discovered to have others still attached to them, and exhib- 
ited traces of the separation of those which were found in 
the vessels. 

Subsequently (in 1852), Dr. Senhouse Kirkes 2 called spe- 
cial attention to the plugging up of the middle cerebral 
artery as a cause of softening of the brain. Three cases, in 
which death followed, are adduced, in each of which the 
condition of non-inflammatory softening was found to exist 
in the brain. Dr. Kirkes's observations appear to have been 
made without any knowledge of Yirchow's prior researches. 
He states that the paralysis met with in young persons may 

1 Ueber die akute Entzundung der Arterien. Archiv fur Pathol. Anato- 
mie, B. i., 1847, p. 272. In a paper on Occlusion of the Pulmonary Artery, pub- 
lished in Froriep's Neue Notizen in 1846, he enunciated a similar theory. 

2 On some of the Principal Effects resulting from the Detachment of Fi- 
brinous Deposits from the Interior of the Heart, and their Mixture with the 
Circulating Fluid. Medico-Chirurgical Transactions, vol. xxxv., 1852. 



PARTIAL CEREBRAL ANEMIA, ETC. 135 

be due to the interruption of a due supply of nutriment to 
the brain by the occlusion of an artery by a plug derived 
from the left side of the heart. 

Schutzenberger, 1 among others, has written with great ful- 
ness on this subject. Among other conclusions not specially 
applicable to the particular point now under consideration, 
he states that fibrinous concretions may form in the heart, 
or large vessels may subsequently be detached and carried 
by the blood to the cerebral arteries, where they produce 
symptoms not essentially different from those noticed in 
cerebral haemorrhage or acute softening. 

The only essential points of difference under this head 
between thrombosis and embolism, are the suddenness of the 
attack, the part of the brain most liable to be affected, the 
origin of the clot, and the state of the blood-vessel which is 
obliterated. 

Relative to the first, the abrupt closure of a vessel as in 
embolism will, of course, produce more violent symptoms 
than if the occlusion has taken place gradually, and thus 
time have been afforded for the establishment of the collat- 
eral circulation. In the first case, not only is the blood at 
once shut off from a portion of the brain, but the vessels be- 
hind the clot receive a greater quantity than they normally 
do, and hence the regions they supply are immediately con- 
gested. In examination of the brain of a person who has 
died during the first stage of cerebral embolism, we find 
those parts of the brain ordinarily supplied by the obliterated 
vessel paler than natural, with a zone of congested tissue, 
and perhaps numerous small extravasations of blood on the 
periphery. 

The place where emboli are most frequently found is, as 
has already been stated, the left middle cerebral artery. The 
left common carotid arises from the arch of the aorta in a 
line almost exactly coinciding with the course of the blood- 
current. It therefore happens that an embolus which has 

1 Gazette des Hopitaux, No. 80, 1857. 



136 DISEASES OF THE BRAIN. 

formed on the lining membrane of the heart, and which has 
passed into the aorta after having been detached, enters this 
vessel instead of the innominata. From the common carotid 
it passes into the internal carotid and thence with the 
stronger and more direct current into the middle cerebral 
artery, which is lodged in the fissure of Sylvius. Of forty- 
two cases of cerebral embolism collected by Meissner, in 
thirty-four the left hemisphere was the seat. Of thirty-seven 
cases occurring in my own practice, and to which reference 
has been made, thirty-one were accompanied with right 
hemiplegia, and were consequently on the left side of the 
brain. Post-mortem examinations were made in seven of 
these cases, and in all the embolus occupied the left middle 
cerebral artery. 

The pathology of the genesis of the clot has already been 
sufficiently dwelt upon in other connections, and the fact 
that the artery in which it is found is not diseased has been 
mentioned. 

The further consequences of embolism belong to cerebral 
softening and will be considered under that head. 

Treatment. — It is not necessary to make any remarks on 
this point in addition to those made in regard to the treat- 
ment of thrombosis. There is very little to be done besides 
meeting indications as they arise, and attempting to relieve 
the paralysis and other vestigia, for which ends my views 
have been sufficiently expressed in the preceding chapters. 



CHAPTEE VI. 

CEEEBBAL SOFTENING. 

As a consequence of several of the conditions described 
in the foregoing pages, and especially as resulting from 
thrombosis and embolism, cerebral softening naturally 
comes next in order for consideration. Most authors treat 
of it in direct connection with obliteration of the cerebral 
arteries, but, although frequently due to this cause, it may 
be produced by others, and occlusion is not always followed 
by softening. For these reasons I have preferred to con- 
sider it as it really is, a distinct pathological condition — as 
much so as sclerosis or any other morbid anatomical state. 

Symptoms. — When softening is the result of haemorrhage, 
thrombosis, or embolism, the symptoms peculiar to those af- 
fections are first met with. Thus there are troubles of the 
intelligence, the sensibility, and the power of motion, such 
as have already been described under the heads mentioned, 
and, if the morbid process goes on within the cranium, there 
are peculiar aggravations and the development of new symp- 
toms. The condition of softening is not set up after either 
haemorrhage, thrombosis, or embolism, till about the tenth 
day, and the symptoms now to be mentioned are those 
which are coincident with what some pathologists have 
designated the " second stage ; " the " yellow softening " of 
others. 

In addition to the continued paralysis of motion and the 
loss of sensibility which exist on one side of the body, the 
mental symptoms become more strongly marked. There 



138 DISEASES OF THE BRAIN. 

may be delirium with the occurrence of hallucinations and 
delusions, though these are generally evanescent. Occa- 
sionally a fixed idea obtains possession of the patient's mind, 
and for a while influences him in his conduct, but his men- 
tal tenacity is not strong enough to enable him to retain it 
for any length of time, so it soon yields to another. 

The intelligence is notably diminished, so that the pa- 
tient is unable to conceive an exact idea of his situation, or 
to obtain a moderately complete notion of quite simple 
matters which may be submitted for his mental action. 
Thus he refuses to credit the assertion that he is ill, declares 
that his health, both in mind and body, is excellent, and 
that he is fully capable of transacting his business or of per- 
forming any intellectual operation. 

The memory is invariably impaired, and things of the 
greatest familiarity are forgotten. Thus a patient laboring 
under cerebral softening, the result of embolism, could not 
tell his wife's name, nor by what means he came to my 
office. Another, sent to me by Dr. Michel, of St. Louis, in 
whom thrombosis was the probable cause, could not tell me 
where he came from, nor the names of his children. He in- 
sisted with great vehemence that he was perfectly able to 
attend to his ordinary business, and yet was unable to add 
three numerals together. 

In another case, likewise having the clinical history of 
thrombosis, which I saw in consultation with my friend Dr. 
J. "W. Kanney, of this city, the patient, a gentleman of 
about sixty years old, could not tell his age ; declared that 
Dr. Ranney, whom he had known for many years, was a 
grocer, " who lived around the corner ; " and held to the de- 
lusion that his sons had made several forcible attempts to 
rob him. 

The power of giving the attention to subjects is very 
greatly lessened. The patient may seem to be listening to 
what is said, or observing what is passing about him, but, if 
he be questioned he at once, shows that he really has not 



CEREBRAL SOFTENING. 139 

been heeding ; even when things are forcibly brought to his 
mind, and he is told to mark them, he is incapable of doing 
so to any considerable extent. 

The speech is almost invariably affected either in the 
form constituting aphasia, or from paralysis of the tongue 
and other muscles concerned in articulation. There is a 
disposition to misplace words, or to clip them by cutting off 
the last syllable. Thus a patient reading the title of a book 
in my library called it the " Unit. Stat. Dispenst." for 
United States Dispensatory ; another was the " Philosoph. 
as Absol. Scien." for Philosophy as Absolute Science ; and 
he told me he was " a lawy. by professi.," when he meant 
to say he was a lawyer by profession. The same fault 
is shown in reading from a printed page, and in writing. 
Only a few days ago I received a letter from a gentleman, 
in which the final letter of nearly every word was omitted. 
The emotions, especially those of a sorrowful character, 
are very easily excited, and therefore the least untoward 
event causes the exhibition of feeling. Sometimes the pa- 
tient sheds tears without being able to assign any cause, 
or may get into uncontrollable fits of weeping ; occasionally 
of laughing. 

All these symptoms indicate failure of the mental power, 
but it is, nevertheless, true that softening of the cerebral tis- 
sue may exist without the manifestation of the least degree 
of imbecility. It not un frequently happens that, while there 
is a general loss of intelligence, some one or two faculties of 
the mind are notably increased in vigor. 

I have a patient now under my charge whose intellectual 
force is greatly reduced, who cannot pronounce the simplest 
sentence correctly, who is paralyzed throughout the whole 
of one side, and who has so lost the sense-of propriety that 
if he feels the desire to urinate he yields to it at once, no 
matter where he may be or who are present, but whose voli- 
tional power is even greater than before the accession of his 
disease. Thus he will read volume after volume, turning 



140 DISEASES OF THE BRAIN. 

over the pages regularly, and scarcely, except by oversight, 
skipping a word, although it is very certain he does not 
comprehend a tenth part of what he reads, and that what he 
does for the moment understand is immediately forgotten. 
The strength of his will is also shown in the impossibility 
of inducing him to do any thing which either caprice or 
habit prompts him not to do. His appreciation of harmony 
has become so sensitive that a discord of sounds made on the 
piano causes him real mental sufferring, whereas when he 
was in health his musical taste and discrimination of the 
pitch and quality of sounds were below mediocrity. 

Drowsiness is very generally present ; at first, perhaps, 
to a slight extent, but sooner or later as a prominent feature. 
Headache is very common, and is usually dull and circum- 
scribed. The forehead is its most common seat. Other 
sensations in the head, such as vertigo, fulness, weight, and 
constriction, are scarcely ever absent. 

Gradually, the condition of the patient, mentally and 
physically, becomes weaker and weaker, and death ensues, 
immediately preceded by coma, convulsions, delirium, or a 
combination of these phenomena. 

Not unfrequently, softening of the brain is not preceded 
by haemorrhage, thrombosis, embolism, or other evident 
affection, but begins obscurely, and advances very gradually. 
In this form the symptoms previously described make their 
appearance in succession ; but the paralysis, instead of being 
present from the inception, comes on very slowly, commen- 
cing as a slight weakness, conjoined with numbness, in one 
or more of the extremities, or in the face. Ordinarily, the 
first evidence of paresis is discovered in the leg, which is not 
lifted clear of the ground. The toe consequently strikes 
against the inequalities of the pavement, and the patient is 
apt to fall. Sometimes the weakness is shown by the leg 
suddenly giving way at the knee. I have had several pa- 
tients with cerebral softening, in whom this accident was of 
common occurrence, and who had thereby received severe 



CEREBRAL SOFTENING. 141 

injuries. Or, when the arm is the paretic member, the 
grasp, as shown by the dynamometer, is materially lessened 
in strength, and things held in the hand are dropped. I 
have now a patient in charge in whom the affection is in its 
very earliest stages, and of which the only manifestations 
are, clipping of the words in speech and paresis of one arm. 

This inability of the muscles to maintain a continuous 
contraction for a short time, though met with in several 
other affections, is to some extent characteristic of cerebral 
softening, and, in conjunction with the other phenomena, is 
a valuable indication. Even before it has become so far 
developed as to attract the attention of the patient or those 
about him, its existence may be ascertained by means of the 
dynamograph described in the preliminary chapter of this 
treatise. It will often be found that a straight line cannot 
be made, but that the pencil pursues a zigzag course, or 
else one descending with more or less regularity. 

The paralysis usually goes on to complete loss of power, 
though its progress is often very slow, and is marked occa- 
sionally by periods of decided improvement. At these 
times the patient's friends imagine that he is about to re- 
cover, and if, as is sometimes the case, the mental symptoms 
are likewise mitigated, their hopes are still further exalted. 
It is necessary that the physician should not be deceived. 
In a case which I saw in consultation with Dr. Chamber- 
lain, of this city, I diagnosticated chronic softening. At 
the time, there were feebleness of memory, paresis of one 
side of the body, and difficulties of speech. I gave an un- 
favorable prognosis, but soon afterward amendment began, 
and the patient, who was an insurance agent or appraiser, 
resumed his business to some extent. I nevertheless adhered 
to my opinion, for I had seen too many cases of similar char- 
acter to be deceived in so clear a one as this. I never saw 
the patient again, and am therefore unacquainted with the 
subsequent phenomena, except that about a year afterward 
I was invited by Dr. Chamberlain to be present at the post- 



142 DISEASES OF THE BRAIN. 

mortem examination. His brain contained a foyer of soft- 
ened tissue as large as a walnut, apparently the result of 
obliteration of the posterior branch of the left middle cere- 
bral artery, and involving a portion of the middle lobe of 
the left hemisphere. 

In another case, which I had very thorough opportu- 
nity for studying, the patient, a gentleman thirty-five years 
of age, was the subject of chronic softening, without any 
history of previous lesions. The disease had come on very 
insidiously, first showing itself by a slight impediment of 
speech and impairment of memory. Gradually he lost 
power in both arms and both legs, though the right side was 
more affected than the left. His gait became titubating, 
and although he never lost the ability to walk, yet he did 
so with great and increasing difficulty. But his stages 
of apparent improvement were at first numerous and well 
marked. His memory at such times was stronger, his coun- 
tenance brighter, his articulation distinct, his emotions more 
under command, his power of attention increased, his in- 
telligence equal to all ordinary occasions, and his walk free 
from any sign of debility. Then all these steps would be 
suddenly lost, and he would again become imbecile and 
weak. Finally, a severe convulsion, more evident on the 
right side than the left, supervened one evening after din- 
ner, as he was quietly smoking a cigar. Between seven and 
twelve o'clock that night he had over a hundred fits. He' 
died at the latter hour. The post-mortem examination re- 
vealed the existence of a large centre of softening, involving 
the middle lobe of the left hemisphere. 

Sometimes the course of the disease is still more irregu- 
lar. E~o evidence of cerebral disorder is perceived beyond 
aphasia, and the patient remains in the full possession of his 
intellect, and without paralysis, up to a short time before 
death. Durand-Fardel 1 cites the case of a man, thirty years 
of age, who entered the Hotel Dieu, presenting all the signs 

1 Traite du Ramollissement Cerebral, Paris, 1843. 



CEREBRAL SOFTENING. 143 

of pulmonary phthisis. In a few days afterward he experi- 
enced difficulty of articulation, in thirty hours he became 
comatose, and, in twenty more, died. The post-mortem ex- 
amination revealed the existence of softening of the inferior 
surface of the left middle lobe of the cerebrum. Although 
it is not so stated — Durand-Fardel having written previously 
to Yirchow's observations — there is little doubt that the 
cause of the softening was an old embolus in the left middle 
cerebral artery. 

Lallemand, 1 in his first letter, cites several cases in which 
the disease was marked by singular symptoms, such as con- 
vulsions, contractions, and delirium. 

In a case which I saw in consultation with Prof. C. A. 
Budd and Dr. J. T. Taylor, occurring in a gentleman about 
thirty-five years of age, there were coma and violent hemi- 
convulsions, evidently due to softening from embolism, of 
which there had been two attacks, the last several weeks 
previously. Death ensued, but no post-mortem examination 
was, I believe, obtained. 

A gentleman is now under my charge who has valvular 
disease on the left side of the heart, the consequence of rheu- 
matic endocarditis, and who, six months since, had an apo- 
plectic attack conjoined with aphasia and right hemiplegia. 
He soon became able to speak pretty well, and regained 
power and sensibility to a great extent in the paralyzed 
limbs. During the past two weeks, however, he has exhib- 
ited symptoms of mental derangement, as shown by the 
existence of hallucinations and delusions, and is gradually 
losing the power of motion and of sensation on the right 
side. His speech is as perfect as it ever was, and there is 
yet no sign of dementia. 

It has happened that individuals have died who, on post- 
mortem examination, were found to have softening of the 
brain, but who, during life, had exhibited no symptoms of 

1 Recherches Anatomico-Pathologiques sur l'Encephale et ses Dependances, 
Paris, 1824. 



144 DISEASES OF THE BRAIN. 

this or any other cerebral disorder. Rostan, who was the 
first to write systematically on the disease, refers to such 
cases, and Durand-Fardel is still more explicit. The latter 
says: 

" We meet with softening of the brain in persons who, up 
to the time of death, had presented no appreciable derange- 
ment of the cerebral functions, and in whom softening has 
been developed without having given any evidence what- 
ever of its existence." In such instances the white matter 
of the hemisphere can alone be involved. 

One such case verified by post-mortem examination has 
occurred within my own experience. The patient, a soldier 
of the Second United States Infantry, died at Tort Riley, 
in Kansas, of which post I was the medical officer, of chronic 
dysentery, the result of exposure. There were no mental 
symptoms, no difficulty of speech, no paralysis ; nothing, in 
fact, indicating the existence of brain-disease. He died in 
full possession of his intellectual faculties. The post-mortem 
examination revealed the existence of ulceration of the small 
intestines, and, as the cause of death was very evident, the 
brain was not examined. I reserved it, however, for pur- 
poses of study, and, on making a section of the right hemi- 
sphere an hour afterward, discovered an encysted centre of 
softening including more than two-thirds of the posterior 
lobe. The right posterior cerebral artery was entirely ob- 
literated by thrombosis. The man had been at the fort for 
several months, and had never made complaint of any illness 
till he was attacked with dysentery six weeks before. 

The duration of cerebral softening is very variable. 
Rostan found it to range from a few days to several years. 
Andral, from an analysis of one hundred and five cases, 
found that the period was from twelve days to three years. 
The most rapid case occurring in my experience terminated 
in death at the end of eighty hours. Some confusion on this 
point has arisen from the fact that some authors regard em- 
bolism and thrombosis as essentially identical with soften- 



CEREBRAL SOFTENING. 145 

ing, a doctrine which is clearly erroneous, as, in many cases 
of these affections, recovery or death may take place with- 
out the stage of softening being reached. In the case above 
referred to, post-mortem examination showed that the condi- 
tion known as yellow softening was just making its appear- 
ance. As I have already stated, I cannot regard the altera- 
tion called by some pathologists red softening any thing 
more than the congestion due to the active collateral circu- 
lation. 

The case of longest duration, of which I have any per- 
sonal knowledge, was that of an eminent scientific gentle- 
man, who had suffered from the symptoms of softening of 
the brain for nearly four years, when he died. There was 
no post-mortem examination, but the history of the case was 
that of thrombosis of the left middle cerebral artery, and the 
course of the disease left no room for doubt as to its na- 
ture. 

When death results, it may be directly due either to the 
disease itself, or to some intercurrent affection. Thus the 
patient may die from pure exhaustion or from slow asphyxia 
caused by the imperfect action of the respiratory function, or 
he may choke to death either by being unable to swallow 
food which he has taken into his mouth, or by the regurgi- 
tation of the contents of the stomach during a convulsion, 
or a severe convulsive seizure may cause immediate as- 
phyxia, or a series of convulsions may produce a more grad- 
ual asphyxia, or he may die in a state of profound coma. 

The intercurrent affections may be either meningitis or 
hypostatic congestion of the lungs from long confinement to 
the recumbent posture, or diarrhoea, or a 'fresh attack of 
thrombosis or embolism. 

Causes. — The etiology of cerebral softening has already 
been considered to some extent under the heads of cerebral 
haemorrhage, thrombosis, and embolism, of which condi- 
tions it is so often a sequence ; but, as it frequently occurs 
without having been preceded by either of these or other 
10 



146 DISEASES OF THE BRAIN. 

noticeable affections, a few additional observations are ne- 
cessary. 

Age is certainly a strong predisposing, if not an actual 
existing canse, although the disease is observed at all periods 
of life. Eostan, whose cases were collected at the Salpe- 
triere, a hospital containing only old women, found that 
there were ten cases in persons between the ages of sixty 
and sixty-nine, twenty between seventy and seventy-nine, 
an'd ten between eighty and eighty-seven. Andral, exclud- 
ing cases occurring in infants, found that, of one hundred 
and fifty-three cases, there were between the ages of 

15 and 20 10 

20 " 30 18 

30 " 40 11 

40 " 50 19 

50 " 60 27 

60 " 70 , 34 

70 " 80 30 

80 " 89 4 

Durand-Fardel, from an analysis of fifty-five cases, found 
between the ages of 

30 and 40 3 

40 " 50 8 

50 " 55 2 

60 " 70 14 

70 " 80 23 

80 " 87 5 

The period of life, therefore, at which softening is most 
apt to occur, is from the age of fifty to eighty. 

During the past six years twenty-eight cases of cerebral 
softening, not the result either of hemorrhage, thrombosis, 
or embolism, have been under my care or been seen by me 
in consultation. Of these one was under twenty years of 
age, three were between twenty and thirty years ; four be- 
tween thirty and forty ; four between forty and fifty ; six 



CEREBRAL SOFTENING. 147 

between fifty and sixty ; eight between sixty and seventy ; 
and two between seventy and eighty. The general results, 
therefore, go to show the greater proclivity which advanced 
age gives to the occurrence of the disease. ' In one of those 
between seventy and eighty, the mind was scarcely impaired 
till about two months before death, though there had been 
paresis, headache, and aphasia, for two years. 

No definite statistics have been collected relative to the 
influence of sex, although the opinion appears to prevail 
that the affection is more liable to occur in females than 
in males. Of the twenty-eight cases just cited, twenty were 
males and eight females. 

The season of the year does not appear to exercise much 
influence. Durand-Fardel, from sixty-three cases, found 
that seventeen occurred in winter, thirteen in spring, twenty 
in summer, and thirteen in autumn. I have found it diffi- 
cult in many cases, from the insidious or latent character of 
the early symptoms, to fix the period of beginning with ac- 
curacy. 

Intense and long-continued intellectual exertion is one 
of the most common causes of cerebral softening. Eleven 
of the cases occurring in my experience were clearly the re- 
sult of this cause. Severe and protracted emotional disturb- 
ance was apparently the cause in four cases. 

Rostan, among the causes, cites insolation, the action of 
intense cold upon the head, blows, and excessive use of alco- 
holic liquors. 

The influence of thrombosis and embolism in producing 
partial cerebral anaemia, and hence as leading to the super- 
vention of softening, has already been dwelt upon at suffi- 
cient length. 

Diagnosis. — The history of hemorrhage, thrombosis, or 
embolism, when these affections have either of them given 
rise to softening, will aid in the diagnosis. The signs which 
serve to distinguish these affections from others have already 
been sufficiently considered. 



148 DISEASES OF THE BRAIN. 

When there is no such previous clinical history, softening 
of the brain may be confounded with chronic meningitis, 
meningeal hemorrhage, or tumors. From chronic menin- 
gitis it is to be distinguished in many cases by the facts that 
in the former the headache is generally diffused, while in 
softening it is fixed, that the paralysis is more limited, that 
there are frequent spasms of the limbs, that there are well- 
marked febrile exacerbations, and that there is not the pro- 
gressive enfeeblement of the intellect so characteristic of the 
vast majority of cases of cerebral softening. At the same 
time it must be admitted that the diagnosis sometimes can- 
not be clearly made out. 

In meningeal hemorrhage coma occurs as an early symp- 
tom, gradually increasing in intensity, whereas in softening 
it comes on at a late period. Hematoma of the dura mater, 
however, may readily be confounded with softening. The 
history of the case will aid in the formation of a correct di- 
agnosis. 

In tumors the most prominent symptoms are pain and 
convulsions, while the intellect usually remains unaffected. 
The pain is exceedingly intense, while in softening it is dull. 
The speech in tumors is generally unaffected. 

Prognosis. — Cerebral softening in general ends in death. 
Nevertheless, it is not altogether hopeless. If the patient 
be young, of good constitution, and of temperate habits ; if 
the centre of softening be small, and not involving the more 
important parts of the brain, there is some encouragement 
to expect a favorable termination. Some of the cases cited 
in this chapter go to show that recovery is possible, and I 
have certainly seen others with the ordinary initial symp- 
toms of cerebral softening recover with appropriate medica- 
tion. Such patients, however, were all under the age of 
forty, and were of good constitution and habits. In soften- 
ing due to embolism, and occurring after rheumatism and 
endocarditis, the liability to future attacks must not be over- 
looked. I have seen as many as six attacks of embolism oc- 



CEREBRAL SOFTENING. 149 

curring in the same patient, and yet no morbid condition 
beyond that of anaemia set up, and again cases in which a 
single embolus has caused softening and death. 

Morbid Anatomy. — In the softening of the brain which re- 
sults from thrombosis or embolism, the first stage after that 
of congestion from the excessive action of the collateral cir- 
culation is what is called yellow softening. This is not, as 
some authors have supposed, produced by the infiltration of 
pus into the cerebral substance, but is caused by regressive 
metamorphosis of the brain-cells into fat, the granules of 
which are mixed with the coloring matter of the blood which 
gives rise to the peculiar yellow color. The white corpus- 
cles of the blood also undergo degeneration into fat. 

These altered white corpuscles were described by Gluge ' 
as inflammation corpuscles, under the idea that softening 
was always the result of inflammation. Labor de, 2 who has 
studied this subject with great success, shows, however, very 
conclusively that the transformation is a true degeneration, 
a part of the fat-corpuscles being derived, as stated above, 
from the nervous fibres, the cylinders of which disappear, 
the contents being extravasated, and with the myeline being 
converted into fat ; and another part consisting of Altered 
white blood-corpuscles. At this time the cerebral tissue is 
pulpy, constituting a centre of softening or a, foyer, the con- 
sistence of which is greater at the circumference than at the 
centre. The blood-vessels passing through the disorganized 
portion are easily separated from the perivascular tissue and 
are covered with oil-globules. 

The second stage is designated white softening, and in it 
the brain-substance loses altogether its morphological char- 
acteristics, and appears as a white, cream-like matter so soft 
that a weak stream of water, allowed to impinge upon it, 
washes it away. In this semi-liquid matter, whitish flakes 
of denser tissue are suspended. Microscopical examination 

1 Atlas of Pathological Histology. Translated by Leidy. Philadelphia, 1853. 

2 Op. cit. 



150 DISEASES OF THE BRAIN. 

shows that all traces of nervous structure have disappeared, 
and that no anatomical elements remain except oil-glob- 
ules and organic corpuscles somewhat resembling leuco- 
cytes. 

"When the morbid process involves the cortical substance 
of the cerebrum, the convolutions undergo a peculiar kind 
of transformation first pointed out by Cruveilhier, and then 
by Durand-Fardel 1 as occurring in the senile form of soft- 
ening. 

This is characterized by the formation of yellow plates, 
irregular in form, soft to the touch, but yet sufficiently dense 
to resist the action of a thin stream of water. Microscopi- 
cally they are seen to consist of nucleated fibres, fat-corpus- 
cles, fat-globules, and degenerated capillaries, with blood- 
crystals and granular matter. Essentially, therefore, they are 
formed of connective tissue. 

The degenerated nerve-tissues, constituting a focus of 
softening, may undergo absorption. In such a case, a cica- 
trix, similar in general characteristics to that resulting from 
the curative process of haemorrhage, remains. 

In the softening resulting from inflammation, a somewhat 
different set of morbid appearances exists. Thrombosis and 
embolism produce a true death of the parts previously sup- 
plied by the occluded vessels, a necrobiosis, as it has been 
called by Yirchow. The process is accompanied, as we have 
seen, by degeneration of the nervous tissue, but in the soft- 
ening due to inflammation new formations result. Some- 
times the two coexist, but the latter is occasionally an en- 
tirely independent action. 

When such is the case, connective tissue is generated, 
and the nervous substance is rapidly broken down. An ex- 
udation of an albuminous fluid containing fine granules, the 
disintegrating nervous substance and numerous flakes of co- 
agulated fibrine, takes place, and with blood-corpuscles causes 
the centre of softening to present the appearance of a red- 

1 Maladies des Vieillards. Paris, 1854, p. 72. 



CEREBRAL SOFTENING. 151 

dish pultaceous mass, easily washed away by the action of a 
weak stream of water. With age the color of this softened 
tissue becomes brown or yellow. Sometimes, when the in- 
flammation has extended to the deeper parts of the cere- 
brum, the contents of the cyst are penetrated by the new 
connective tissue. The pulpy mass undergoes partial ab- 
sorption, and is replaced by a white turbid liquid, called by 
Cruveilhier and Dechambre " milk of lime " (lait de chaux). 
Durand-Fardel designates this form of softening " cellular 
infiltration.'' 

The softening resulting from occlusion of the capillaries, 
a condition not recognizable during life, does not differ es- 
sentially, except in its situation, from that which follows 
thrombosis or embolism. The centres of the process are, 
however, smaller, and are generally numerous. 

When disease of the capillaries has been the cause of the 
softening, these may be ruptured, and we meet with minute 
extravasations of blood in the disintegrated perivascular 
tissue constituting the " capillary haemorrhage " of Cruveil- 
hier. 

Pathology. — The first definite accounts of cerebral soften- 
ing were given by Lallemand 1 and Eostan, 3 both of whom 
published their works in the same year, 1820. 

In the very beginning of his first letter, Lallemand awards 
to MM. Recamier, Bayle, and Cayot, the credit of describing 
the condition under consideration, and of giving it the desig- 
nation by which it is so generally known, even out of France, 
of ramollissement. Lallemand then proceeds to define the 
term by saying that, by ramollissement of the brain, he under- 
stands a kind of liquefaction of a part of its substance, the re- 
mainder preserving its ordinary consistence. He then quotes 
cases from Morgagni and Abercrombie, and cites others from 
his own experience ; and then concludes by declaring that he 

1 Recherches Anatomico-Pathologiques sur l'Encephale. Paris, 1820. 

2 Recherches sur le Ramollissement du Cerveau. Paris, 1820. My refer- 
ences to Rostan's work are to the second edition, of 1823. 



152 DISEASES OF THE BRAIN. 

does not hesitate to range cerebral softening among the in- 
flammations, in which opinion he is supported by Abercrom- 
bie. 1 Rostan 2 regarded the disease as sometimes being due 
to inflammation, and sometimes to degeneration of the 
blood-vessels. Bouillaud 3 viewed it as an anatomical fea- 
ture of inflammation. Cruveilhier 4 considered what he 
called red softening as resulting from the capillary haemor- 
rhage previously mentioned, and that other forms were cer- 
tainly due to inflammation. 

Andral 6 recognized the fact that softening might result 
from inflammation or capillary haemorrhage, but he also in- 
sisted that it might be due to special alterations of nutrition, 
caused by different morbid influences, such as obliteration 
of the arteries supplying the brain, or impoverishment of 
the blood. 

MM. de la Berge and Monneret 6 adopted in part the views 
of Rostan relative to degeneration of the cerebral vessels as 
a cause of softening. Carswell 7 regarded softening occur- 
ring during life as being effected by these circumstances — 
inflammation, obliteration of arteries, and modification of 
nutrition. 

Fuchs 8 appears to think that inflammation is not a ne- 
cessary antecedent, but that congestion is. He also admits 
obstruction of the arteries at the base of the brain to be a 
cause. 

The studies of Durand-Fardel 9 have been very thorough, 
and have contributed greatly to our knowledge of cerebral 
softening. According to him, the affection is an inflamma- 

1 Op. cit., p. 205. 2 Op. cit., Chapter VII. 

3 Traite de l'Encephalite. Paris, 1825. 

4 Art. Apoplexie, in Dictionnaire de Medecine et de Chirurgie Pratique. 

5 Clinique Medicale. 

6 Compendium de Medecine Pratique. 

7 Art. Softening of Organs, in Cyclopgedia of Practical Medicine, vol. iv., p. 
176, American edition. 

8 Beobachtungen und Bemerkungen iiber Gehirnerweichung. Leipzig, 1838. 
8 Traite du Ramollissement du Cerveau, Paris, 1843. 



CEREBRAL SOFTE^'G. 153 

tion which does not differ essentially from other inflamma- 
tions occurring in the young or old. "White softening he 
regards as the chronic form of the disease. 

Other pathologists published the results of their obser- 
vations and generally to the same effect as those which have 
been quoted, viz., that cerebral softening was an inflamma- 
tory process, and sometimes one resulting from obliteration 
or disease of the arteries. A few, however, held to the view 
of Lallemand and Durand-Fardel, that inflammation was 
always the starting-point. 

In 1847 Virchow published his observations relative to 
embolism, and the partial cerebral anaemia produced by oc- 
clusion of an artery thus became a recognized fact. In 
reality, it came to be regarded as the only cause capable of 
giving rise to softening, and many pathologists of the pres- 
ent day entertain such an opinion. But I think this is car- 
rying the theory further than facts will warrant. I can- 
not altogether disregard the researches of Durand-Fardel, 1 
Calmeil, 2 Rokitansky, 8 Wedl,* and others, and although I 
cannot agree that all cerebral softening is a consequence of 
inflammation, I am very sure it has this and other causes 
besides thrombosis and embolism. Calmeil's work is a mon- 
ument of careful observations and scientific deductions, and 
his fifth chapter (t. ii.), entitled " Du Ramollissement cere- 
bral local aigu, ou de V Encephalite locale aigue sans caillots 
sanguins siegeant sous la forme cVun foyer ou des jplusieurs 
foyers circonscrits, soit a la surface, soit dans la jprofon- 
deur de la masse encephalique" contains cases which are 
amply sufficient to establish the point for which he contends. 
He shows, too, in other chapters of his treatise, that soften- 
ing results about the periphery of clots due to cerebral haem- 
orrhage. 

1 Maladies des Vieillards, Paris, 1854. 

3 Traite des Maladies Inflammatoires du Cerveau, Paris, 1859. 

3 Pathological Anatomy, Sydenham Society, translation, 1850. 

4 Rudiments of Pathological Histology, Sydenham Society, translation, 1855. 



154: DISEASES OF THE BRAIN. 

The weak feature of Calmeil's otherwise very complete 
work is, that he altogether ignores Yirchow, and those after 
him, who have confirmed his facts and theories. 

Soulier, 1 on the other hand, can see in softening nothing 
of the nature of inflammation. For him it is always a ne- 
crobiosis, produced by the cessation of the physiological ac- 
tion of the blood, obliteration by embolus or thrombus, by 
diminution of the calibre of the vessels, or occlusion result- 
ing from atheroma or obstruction of a vein or sinus. He 
admits that the obliteration of an artery may cause conges- 
tion behind the point of obstruction, by which the coagula- 
tion and capillary haemorrhage of acute softening — the capil- 
lary apoplexy of Cruveilhier — are to be explained. This 
red ramollissement has, however, nothing of the nature of 
inflammation about it. 

The only points in which I differ with Soulier are, that 
I cannot regard softening as being solely due to occlusion 
of blood-vessels, and that I am very sure the congestion 
which follows thrombosis or embolism is not necessarily the 
first stage of softening. There is no more reason why par- 
tial cerebral anaemia should always result in softening, than 
that ligation of the femoral artery should always lead to 
gangrene of the parts below. 

Obstruction of veins and sinuses in the brain may be fol- 
lowed by softening. The clot is usually the result of inju- 
ries or disease of the cranial bones or cerebral membranes, 
especially the dura mater. It may also be caused by cer- 
tain cachectic conditions in which the blood is deteriorated 
in quality, such as typhus and typhoid fevers and cholera. 

Four cases, in which this latter affection was followed by 
thrombosis of the superior longitudinal sinuses, with consec- 
tive softening, have come under my observation. In two of 
them there were also thrombi in both femoral veins. The 
upper surfaces of both hemispheres were the seats of the 
softening, which involved the gray matter only. 

1 Journal de Medecine de Lyon, Fevrier, 1867. 



CEREBRAL SOFTENING. 155 

Thrombosis of the veins or sinuses may also in general 
terms be produced by whatever cause is capable of retard- 
ing the current of blood. Mr. Toynbee, 1 in his chapter on 
diseases of the mastoid cells, has brought forward several 
cases in which the lateral sinus was occluded by coagula, 
and in which there was cerebral softening. 

Cerebral softening may also result from the formation of 
adventitious growths, or from the presence of foreign bodies 
in the brain. In such cases the process begins with inflam- 
mation, and is similar to the action which sometimes goes 
on around an extravasation of blood. 

Acute cerebritis or meningitis may likewise result in soft- 
ening. This fact is admitted by Drs. Russell Reynolds and 
Bastian, in their admirable essays on cerebritis and softening 
of the brain, though with evident reluctance. 

We see, therefore, that cerebral softening may be caused 
either by anaemia or inflammation, and that it is of two 
kinds, inflammatory and non-inflammatory. The seat of 
the softening may be in any part of the brain, although 
some regions are more liable than others. When due to 
thrombosis, there appears to be no predilection for any par- 
ticular location, but, as embolism is generally found on the 
left side in the middle cerebral artery, the parts of the brain 
supplied by this vessel are more liable than the correspond- 
ing parts of the right side. 

Durand-Fardel, however, did not arrive at this conclu- 
sion. Of one hundred and sixty-nine cases of softening, he 
found the left hemisphere the seat in sixty-nine, the right in 
seventy-one, both in twenty- six, and the middle line in 
three. 

The gray matter is generally supposed to be more fre- 
quently the seat of softening than the white. It is true that, 
of thirty-three cases of acute softening observed by Durand- 



1 The Diseases of the Ear, their Nature, Diagnosis, and Treatment : London, 
1860. 



156 DISEASES OF THE BRAIN. 

Fardel, 1 the convolutions were involved in thirty-one, but 
in nine only were they the sole part affected. 

In fifty-three cases which the same author collected from 
the writings of Eostan, Lallemand, and others, the centres 
of softening were found to be as stated in the following table. 
Occasionally more than one region was involved. 

Convolutions and white substance 22 

Convolutions alone 6 

White substance alone 5 

Corpus striatum and optic thalamus 6 

Corpus striatum alone 11 

Optic thalamus alone 4 

Pons Varolii 3 

Crux cerebri 1 

Corpus callosum 1 

Walls of the ventricles (septum) 1 

Fornix 1 

Cerebellum 1 

Bastian, 8 has therefore erred in citing these statistics as 
showing the greater liability of the convolutions; for in 
six cases only were the convolutions the sole seat of the dis- 
ease. 

Eostan, on the other hand, found the corpora striata, 
around the optic thalami, to be the parts most frequently 
affected, and after these the central part of the hemispheres. 
He met with but few cases involving the median line. 

As regards the frequency with which the convolutions 
with the white substance were involved, as compared with 
the motor tract, he found that, of one hundred and seventy- 
seven cases of acute and chronic softening, the convolutions 
were affected in one hundred and nineteen, and the corpora 
striata and optic thalami in fifty-eight. 

The middle lobe is more liable than any other, as is seen 
in the following statement of Durand-Fardel, based upon an 
analysis of ninety-five cases : 

1 Traite du Ramollissement du cerveau, Paris, 1843. 2 Op. cit. 



CEREBRAL SOFTENING. 157 

Posterior lobe 18 

Middle 51 

Anterior 13 

Posterior and middle 7 

Posterior and anterior 2 

Middle and anterior 2 

Whole convexity of hemisphere 1 

Middle line 1 

In more than one-half of the cases, therefore, the middle 
lobe was the seat of the disease. 

A question connected with the pathology of cerebral 
softening, as with haemorrhage, is, Can we determine, from a 
consideration of the symptoms, what part of the brain is the 
seat of the lesion % The answer mnst be the same. "We can 
do so with some approach to accuracy, but, till we are better 
acquainted with the physiology of the different ganglia com- 
posing the brain, we cannot expect to do so with absolute 
certainty. Indeed, owing to the greater extent of tissue in- 
volved, compared to that affected in haemorrhage, we have 
a more complicated set of phenomena to deal with. I have 
nothing further to add to the remarks made on a similar 
point, under the head of cerebral haemorrhage. 

Treatment. — The treatment proper for cerebral softening 
should depend very much upon the cause from which it has 
arisen, and must more or less be directed against the symp- 
toms which are manifested. Thus, if there is reason to sus- 
pect the existence of thrombosis or embolism, and a con- 
sequent anaemic condition of a portion of the brain, the judi- 
cious use of stimulants and tonics is advisable, while the 
body should be kept warm by additional clothing, or the 
application of artificial heat — at the same time the recum- 
bent posture should be assumed, and the head supported on 
a low pillow. Mental exertion should, of course, be ab- 
solutely interdicted. If there be much headache, it is prob- 
ably due to too great an activity of the collateral circulation, 
and in such a case some one of the bromides may be given 



158 DISEASES OF THE BRAIN. 

in large doses, repeated as often as may be necessary. I 
have frequently seen great relief follow their administration. 

Delirium is often due to a like cause and may be similar- 
ly treated. Dr. Eeynolds ' speaks highly of the Indian hemp 
in doses of a quarter to half a grain of the extract ; but, I 
have found the bromide of potassium, in doses of thirty grains 
every three or four hours, more efficacious. 

It is also the most beneficial remedy in the convulsions 
which frequently precede a fatal termination. 

In that form of softening which is obscure in its origin 
and gradual in its progress, there is a little more hope of a 
favorable result, though even here it must be confessed that 
treatment is not often effectual. Still, as I have said, when 
speaking of the prognosis, there are undoubtedly cases in 
which recovery has taken place, and I am very sure that I 
have several times succeeded in curing individuals who, so 
far as I have been able to judge, were affected with cerebral 
softening. As these cases are interesting in themselves, and 
as the histories will show the means of treatment employed, 
I do not hesitate to transcribe the following typical ones 
from my case-book : 

I. — Mr. R., a gentleman, twenty-four years of age, awoke 
one morning about the middle of March, 1870, with a sen- 
sation of numbness extending through the whole of the left 
arm and leg, and with a feeling of vertigo which was insup- 
portable when he arose from the bed. He sat down in a 
chair, and while in this position was conscious of a buzzing 
sound in the right ear. In the course of half an hour the 
vertigo passed off, but the numbness and sound in the ear 
remained, and he occasionally saw double. In a few days 
afterward he noticed a slight difficulty of articulation, owing 
to apparent thickness of the tongue, and about the same 
time observed that in the morning the pillow was wet with 
the saliva which had run from his mouth during sleep. His 
uncle, a wealthy gentleman of this city, sent him off travel- 

1 Article, Softening of the Brain, in System of Medicine, vol. ii. 



CEREBRAL SOFTENING. 159 

ling, but lie returned in a few weeks with loss of power in 
the left arm and leg, which had begun to be manifested to a 
slight extent before his departure. He came under my 
charge May 15, 1870. 

At this time the paralysis, of both motion and sensation, 
was well marked on the left side, as shown by the sesthesi- 
ometer and dynamometer. The line made by the dynamo- 
graph with the right hand was perfectly straight, while that 
made by the left was at an angle of forty- five degrees with 
the other. In his conversation he clipped his words, and 
sometimes left out the smaller ones. His memory he stated 
was materially impaired. There was almost constant head- 
ache over the whole frontal region, and attacks of vertigo 
were frequent. There was no marked paralysis of the face, 
though the muscles of both sides were paretic, and he often 
had double vision. The right pupil was largely dilated and 
was insensible to light. 

Ophthalmoscopic examination showed the left eye to be 
perfectly normal, but the retinal vessels of the right were 
smaller and straight, and the choroid was paler than nat- 
ural. 

Upon inquiry I ascertained that he had given extraordi- 
nary attention to his business for a period of several months 
before the attack of numbness, frequently being up making 
calculations till three o'clock in the morning, and thus de- 
priving himself of the necessary amount of sleep. 

My opinion was, that he was suffering from incipient soft- 
ening of the brain due to disease of the capillaries, which, in 
its turn, resulted from cerebral congestion and exhaustion. 
I was further of the opinion that the lesion involved the 
right hemisphere and motor tract. 

I prescribed the phosphide of zinc in the dose of the 
tenth of a grain, with half a grain of extract of nux-vomica 
in pill three times a day, with the constant galvanic current 
three times a week, the latter to be derived from fifteen of 
Smee's cells, and to be passed from forehead to occiput for 



160 DISEASES OF THE BRAIN. 

three or four minutes at a time. At the end of ten days he 
had lost his diplopia, the pupil of the left eye had regained 
its natural diameter and irritability, and the vertigo and 
headache had notably diminished. The treatment was con- 
tinued, and at the end of a month he had recovered the sen- 
sibility and power on the paralyzed side to such an extent, 
and had improved so much in other respects, that I advised 
him to take a short journey. He was absent two weeks, 
during which period he continued to take the pills as before, 
and on his return was, to all appearance, well. He has since 
remained in excellent health. 

II. — Mr. E. W., a merchant of this city, consulted me 
in April, 1868, under the following circumstances : 

After a long period of great domestic anxiety, during 
which he had been engaged in some heavy commercial 
transactions, and had suffered from wakefulness, he expe- 
rienced one afternoon, while riding in the park in his car- 
riage, a slight quivering motion at the apex • of the tongue. 
It continued until he reached home ; and then, upon look- 
ing in a mirror, he could see the fibrillary movement very 
distinctly. He was not alarmed, and went to bed at his 
usual hour. In the morning he noticed a little thickness 
of speech, but the movement had ceased. That afternoon 
he had a violent headache, attended with vertigo and nau- 
sea. Becoming alarmed, he sent for his family physician, 
who ascribed the symptoms to indigestion, and administered 
a mild cathartic. The following day, on attempting to rise 
from the bed to go to the water-closet, he was attacked with 
such a severe vertigo that he was obliged to lie down again ; 
and, though he did not for a moment lose consciousness, his 
faeces escaped from him involuntarily. From this time he 
gradually lost strength in both arms and legs, and his speech 
became very defective. His memory suffered to such an 
extent that he forgot the names of his children. There was 
very little headache, the vertigo had ceased, there was no 
disturbance of vision, and no loss of power over the sphinc- 



CEREBRAL SOFTENING. 161 

ters. About six weeks after the occurrence of the first symp- 
tom noticed, he came under my care. 

At this time there was anaesthesia of both sides of the 
body, both legs and both arms had lost power ; he clipped 
his words, and frequently substituted others of similar sound 
or meaning for those he ought to have used. His memory 
was much weakened, and there was a strong tendency to 
stupor. There were no troubles of the special senses — 
ophthalmoscopic examination revealed nothing abnormal — 
there was no facial paralysis. I diagnosticated softening of 
the brain from general cerebral anaemia consequent upon 
congestion and cerebral exhaustion, and I prescribed a lib- 
eral allowance of wine, a full and nutritious diet, carriage 
exercise, and amusements of various kinds. This was the 
very reverse of the treatment to which he had been sub- 
jected. In addition, I recommended the constant galvanic 
current, to be applied as in the previous case, and gave the 
following prescription : ^ • Oleii phosphorat. § ss ; mucil. 
acaciae, g j ; ol. bergamot gtts. xv. M. ft. emulsion. 
Dose, gtts. xv. ter die. 

The treatment was carried out with the result of obtain- 
ing a gradual and permanent improvement, so that at the 
end of about six months the patient was well. He then 
went to Europe, where he now is, with as good health as he 
has ever enjoyed. 

Three other cases, similar in their general features, have 
been under my care with a like result in each, and several 
others have been very decidedly improved and relieved of 
the more prominent symptoms of the disease without, how- 
ever, regaining full health. The means of treatment thus 
far consist in the use of tonics, stimulants, and especially 
phosphorus and strychnine, the avoidance of all severe men- 
tal exertion, and all excessive emotion, open-air exercise, 
and the use of the constant galvanic current. 

The beneficial effects of maintaining the physical 
strength were several years since pointed out by Mr. F. 
11 



1^2 DISEASES OF THE BRAIN. 

Skey * in a clinical lecture delivered at St. Bartholomew's 
Hospital, but it must be confessed that the opposite plan 
of treatment has been very generally followed. 

Softening from the effects of thrombosis or embolism is, 
as I have said, not much under the control of the physician. 
Patients recover from it, however, when they are of good 
constitution, and when the focus of softening has not been 
extensive. The mind and body may, and in such cases gen- 
erally do, remain false, and we are therefore consulted for 
the relief of the condition. In such cases tonics, and among 
them phosphorus, strychnine, and wine, occupy a prominent 
place ; the constant galvanic current to the head, and the 
induced to the paralyzed muscles, will rarely fail to be of 
service. 

III. — Thus a gentleman, who had been a distinguished 
officer of the army, suffered from loss of memory, defective 
articulation, ptosis, double vision, and right hemiplegia, prob- 
ably the result of embolism. Several years before he came 
under my charge, he had been treated by my friend Dr. J. T. 
Metcalfe, for heart-disease, the result of acute rheumatism. 
I gave the phosphide of zinc and extract of nux-vomica 
according to the formula previously mentioned, advised a 
liberal use of wine and beefsteaks, applied the primary 
current to the brain, and the induced to his paralyzed arm 
and leg, and in a few weeks had the satisfaction of seeing 
such a degree of improvement as almost to constitute a cure. 
The ocular troubles had disappeared, his memory had im- 
proved, he talked as well as ever, and the numbness and 
loss of strength were no longer remarked unless he over- 
exerted himself, which, owing to his general feeling of Men 
aise, he was very apt to do. He remained in this condition 
for over a year, when he had several other attacks of embo- 
lism, each of which left him more weak, mentally and physi- 
cally, than before, and of which he eventually died. 

1 On the Value of Tonic Treatment in some Diseases of the Brain, more es- 
pecially cases of Ramollissement. Dublin Hospital Gazette, November, 1858. 



CEREBRAL SOFTENING. 163 

There were some interesting features connected with this 
case, which will be referred to at greater length hereafter. 

IV. — In another case, in which there was reason to think 
a foyer of softening had been absorbed, a marked relief from 
the sequelae was obtained. The patient, a literary gentleman 
of distinction, had, several years previously to my seeing 
him, suffered from an attack of acute rheumatism with en- 
docarditis. About a month after his recovery, as he was 
sitting in his library before the fire, he felt a sensation as if 
one side of his face had suddenly become much heavier than 
the other. Almost immediately afterward he lost conscious- 
ness, and fell to the floor. He could not have been in this 
condition longer than five minutes when he came to him- 
self, to find that he was paralyzed in the right arm and leg. 
Attempting to call for assistance, he found he could not 
articulate. His wife soon afterward entered the room, and 
medical aid was obtained. He was bled to the extent of 
sixteen ounces, and purged with croton-oil. 

The following day he was much better ; could move his 
arm and leg, and articulate with some degree of distinctness, 
but toward evening headache ensued, he became delirious, 
and the paralysis increased. Of the condition immediately 
following, he could give no very clear account. He only 
knew that he was confined to his bed for several weeks, was 
delirious part of the time, and that, after the acute attack 
passed off, he was left with an enfeebled mind, imperfect 
articulation, and paralysis of the arm and leg on the right 
side. He went to Europe, travelled extensively, and re- 
turned at the end of a year very much improved, but still 
with some degree of mental weakness, defective speech, and 
paralysis, remaining. 

"When he came under my observation, the following 
were the principal symptoms observed : The strength of 
the right arm, as measured with the dynamometer, was not 
one-third that of the left ; the extensors of the leg and foot 
were almost entirely paralyzed, so that in walking he ab- 



164: DISEASES OF THE BRAIN. 

ducted the leg so as to cause the foot to clear the ground * 
electro-muscular contractility was much weakened, though 
the induced current caused feeble contractions. His speech 
was affected mainly as regarded the memory of words. He 
spoke with a good deal of volubility, but constantly used 
the wrong expressions. Thus, when he wished to tell me 
that he had visited Europe for the benefit of his health, he 
said : " I went to elope for the bequest of my hedge," and 
then went on — continually making other mistakes — to tell 
me a long story which I could scarcely understand. His 
emotions were easily disturbed : he cried because he had to 
wait a few minutes in my reception-room before seeing me. 

Ophthalmoscopic examination showed pale choroids and 
straight and attenuated retinal vessels. Auscultation re- 
vealed the existence of both mitral and aortic regurgitation. 

Taking into consideration the history of the case and the 
present condition of the patient, I diagnosticated embolism 
of the left middle cerebral artery, subsequent softening and 
eventual absorption of the diseased part of the brain. My 
idea was that the brain, as a whole, was ansemic, and that, 
with improved nutrition of it and the paralyzed limbs, 
amelioration of the symptoms was possible. 

I therefore prescribed the phosphide of zinc and nux- 
vomica pills as before mentioned, directed the use of wine 
to the extent of half a bottle of champagne daily, and ad- 
vised that animal food should form the principal portion of 
each meal. Since his illness he had, by direction of his phy- 
sician, left off the use of coffee. I directed it to be resumed, 
and to be taken strong. The primary galvanic current was 
passed through the head in the manner previously indicated 
in this chapter, and the induced current was applied for half 
an hour three times a week to the arm and leg, each para- 
lyzed muscle receiving a full share of attention. 

It was not long before signs of amendment were noticed. 
His strength became greater in the arm, and he was able to 
extend the leg and to raise the foot after half a dozen elec- 



CEREBRAL SOFTENING. 165 

trical applications. His speech next gave evidence of im- 
provement, and his mind became stronger. The treatment 
was continued for about four months, with only an inter- 
mission of a week. At the end of that time his gait was 
almost natural, though he still swung the foot a very little, 
his arm was nearly as strong as the other, his mind was not 
perceptibly weaker than that of other persons of his age 
(fifty-five), and his speech was excellent except when he was 
excited and very anxious to express himself correctly and 
fluently. 

There is one point in regard to which a few words are 
perhaps necessary, and that is to enter a protest against the 
use of counter-irritation of any kind, and to discountenance, 
as far as I can, the employment of the actual cautery. I have 
never seen the least advantage follow the application of cro- 
ton-oil to the shaven scalp, nor can I conceive how such a 
measure can be recommended on rational grounds. I have 
several times witnessed its action, and have invariably seen 
it aggravate the symptoms. In the case of a gentleman from 
St. Louis, affected with cerebral softening, the effect was to 
make his speech still more imperfect and his mind weaker. 
A lady, who was affected with all the more prominent symp- 
toms of softening of the brain, had all the phenomena in- 
creased in violence after the application of the actual cautery 
to the nape of the neck. I could easily adduce other ex- 
amples to the same effect, were it necessary. 



CHAPTEE VII. 

APHASIA. 

The subject of aphasia is of such interest, and so much 
attention has recently been given to it by physiologists and 
pathologists, that, although it is only a symptom common to 
several morbid conditions, a treatise on diseases of the ner- 
vous system would scarcely be regarded as complete without 
its being fully considered. 

By aphasia is understood a condition produced by an af- 
fection of the brain by which the idea of language, or of its 
expression, is impaired. The word is derived from the Greek 
— a, privative, and <£acrt?, speech — and, as stated by Trous- 
seau, was proposed by M. Chrysaphis, a distinguished Greek 
scholar, as a substitute for alalia, used by Lordat, and aphe- 
mda, employed by Broca, to designate the same condition. 

In the definition which I have given of aphasia, the term 
is limited to impairment of the idea of language or of its 
expression. It does not, therefore, include those cases in 
which the individuals are able to speak, but will not ; such as 
are met with among the insane. The idea of language is as 
perfect as ever, and is doubtless entertained, but the person 
does not speak because he does not will to do so, and this fail- 
ure may arise either from a lack of the necessary power, or 
from a stubborn determination not to speak. A lady was a 
short time since under my charge who had been treated by a 
homoeopathic physician as a case of aphasia. A very slight 
examination was sufficient to convince me that the case was 
one of hysteria. She had not spoken for several months, but 



APHASIA. 167 

upon one occasion she came to my office with her maid, 
whom she required to repeat the alphabet, and when the 
right letter was reached she signified the fact by raising her 
hand. She thus spelled out the words she wished to use. 
Subsequently she procured a card with all the letters on it, 
such as are used for children learning their alphabet, and 
she composed her words from this. Of course all these facts 
showed that her idea of language was intact, but she still 
might have lost the power of coordinating the muscles con- 
cerned in articulation so as to express herself in spoken 
words. Although I was sure this was not the case, I failed 
to make her speak, until one morning, she became very much 
interested in something I was saying, and, finding her alpha- 
bet too slow a means of expression, dropped it and began to 
speak with great fluency. After talking with energy for a 
quarter of an hour, she suddenly recollected herself and took 
up her card of letters again, but the charm was broken, and 
by degrees she resumed her speech. At one time this lady 
was under the care of my friend Prof. Flint, for some 
chest or throat difficulty, and on one occasion spoke very 
well. 

Neither does aphasia embrace cases of inability to speak 
from paralysis of the tongue or other muscles of articu- 
lation. Defective speech from this cause is frequently met 
with in hemiplegia, in glosso-laryngeal paralysis, and some 
other affections. In such instances the idea of language re- 
mains, but the patient does not speak because he is unable 
to put the organs of articulation in motion. A few days 
ago a gentleman, a prominent merchant of the city, was 
sent to me as a case of aphasia. As he entered my consult- 
ing-room, I saw that he was hemiplegic on the left side, and, 
on telling him to put out his tongue, found that he could 
not get it beyond the teeth, or touch the roof of his mouth 
with it. The history of the case was that of ordinary cere- 
bral haemorrhage, and he regained the power of speaking 
after several applications of the primary and induced gal- 



168 DISEASES OF THE BRAIN. 

vanic currents had been made to the tongue and muscles of 
the face. 

The distinction between aphonia and aphasia must also 
be made. In the one the idea of speech is undisturbed, and 
articulation is not interfered with except as regards phona- 
tion. Aphonic patients can whisper, but are unable to 
speak in full voice, owing to some laryngeal affection im- 
pairing the tone of the vocal cords. 

The fact that the faculty of speech may be deranged in- 
dependently either of the will, paralysis, or loss of voice, 
appears to have been noticed at a very early period in the 
progress of science. Thus Isaiah 1 says, "For with stam- 
mering lips and another tongue will he speak to this peo- 
ple; " and again, 2 " Thou shall not see a fierce people, a peo- 
ple of a deeper speech than thou canst perceive ; of a stam- 
mering tongue that thou canst not understand." 

Thucydides mentions that many, who suffered from the 
plague which raged at Athens, found on recovering that 
they had not only forgotten the names of their friends and 
relations, but also their own names. 

Pliny, 3 in the chapter entitled Memorice Exemjpla, says, 
in speaking of this faculty : " For nothing is so weak in man ; 
disease, falls, injuries, even a fright, may impair it partially, 
or destroy it altogether. A blow from a stone has abolished 
the memory of the alphabet. A fall from a high roof has 
caused a man to cease to recognize his mother and neigh- 
bors, another even forgot his slaves, and Messala Corvinus, 
the orator, could not recall his own name." * 

Suetonius 6 relates that Claudius so far lost his memory 
that he forgot the names of persons to whom he desired to 
speak, and could not even recollect the words he wished to 
use. 

1 Chapter xxviii. 11. 2 Chapter xxxiii. 19. 3 Lib. vii., cap. xxiv. 

4 Trousseau has translated this passage somewhat differently. I quote from 
an illuminated copy printed at Tarvisium (Treviso), in October, 1479. 
6 C. Suetonii Tranquilli, xii., Caesares. 



APHASIA. 169 

Passing over several authors of later times who have rec- 
ognized the existence of the difficulty in question, we come 
to Crichton, 1 who remarks as follows : " There is a very sin- 
gular defect of memory, of which I have myself seen two 
remarkable instances. It ought rather to be considered as 
a defect of that principle by which ideas and their proper 
expressions are associated, than of memory, for it consists in 
this, that the person, although he has a distinct notion of 
what he means to say, cannot pronounce the words which 
ought to characterize his thoughts. The first case of this 
kind which occurred to me in practice was that of an attor- 
ney much respected for his integrity and talents, but who 
had many sad failings to which our physical nature too 
often subjects us. Although nearly in his seventieth year, 
and married to an amiable lady much younger than himself, 
he kept a mistress, whom he was in the habit of visiting 
every evening. The arms of Yenus are not wielded with 
impunity at the age of seventy. He was suddenly seized 
with great prostration of strength, giddiness, forgetfulness, 
insensibility to all concerns of life, and every symptom of 
approaching fatuity. His forgetfulness was of the kind al- 
luded to. When he wished to ask for any thing, he constantly 
made use of some inappropriate term. Instead of asking 
for a piece of bread, he would probably ask for his boots ; but, 
if these were brought, he knew they did not correspond with 
the idea he had of the thing he wished to have, and was there- 
fore angry. Yet he would still demand some of his boots 
and shoes, meaning bread. If he wanted a tumbler to drink 
out of, it was a thousand to one he did not call for a certain 
chamber utensil, and, if it was the said utensil he wanted, he 
would call it a tumbler or a dish. He evidently was con- 
scious that he pronounced wrong words, for, when the proper 

1 An Inquiry into the Nature and Origin of Mental Derangement, compre- 
hending a Concise System of the Physiology and Pathology of the Human 
Mind, and a History of the Passions and their Effects. London, 1*798, vol. i., 
p. 371. 



170 DISEASES OF THE BRAIN. 

expressions were spoken by another person, and he was asked 
if it were not such a thing he wanted, he always seemed 
aware of his mistake, and corrected himself by adopting the 
appropriate expression. This gentleman was cured of the 
complaint by large doses of valerian and other proper medi- 
cines." 

Dr. Crichton subsequently met with another case simi- 
lar to the foregoing, and he quotes the following from Prof. 
Gruner, of Jena, in vol. vii. of the Psychological Magazine. 
The patient, a learned gentleman, after his recovery from an 
acute fever, suffered a loss of memory for words. Among 
the first things he desired to have was coffee (Jcqffee), but, in- 
stead of pronouncing the letter f, he substituted in its place 
a z, and therefore asked for a cat (Jcazze). In every word 
which had an f he committed a similar mistake, substitut- 
ing a z for it. 

He also cites, from Yan Goens, the case of Madame Hen- 
nert, wife of the professor of mathematics at Utrecht, who 
suffered a similar defect of memory. "When she wished to 
ask for a chair she asked for a table, and when she wanted 
a book she demanded a glass. But, what was singular in 
her case was, that when the proper expression of her 
thought was mentioned to her, she could not pronounce 
it. 

She was angry if people brought her the thing she had 
named instead of the thing she desired. Sometimes she 
herself discovered that she had given a wrong name to her 
thoughts. This complaint continued several months, after 
which she gradually recovered the right use of her recollec- 
tion. It was only in this particular point that her memory 
seemed to be defective, for M. Yan Goens assures us that 
she conducted her household affairs with as much regularity 
as she ever had done, and that she used to show her husband 
the situation of the heavens on a map with as much accu- 
racy as when she was in perfect health. 

The following case, in Gesner's Endeckungen der JVeues- 



APHASIA. 171 

ten Zeit in der Arzneigelehrheit, is likewise quoted by 
Crichton : 

" A man, aged seventy, was seized, about the beginning 
of January, with a kind of cramp in the muscles of the 
mouth, accompanied with a sense of tickling all over the 
surface of the body, as if ants were creeping over it. On 
the 20th of the same month, after having experienced an 
attack of giddiness and confusion of ideas, a remarkable 
alteration of his speech was observed to have taken place. 
He articulated easily and fluently, but made use of strange 
words, which nobody understood. The number of these 
does not at present seem to be great, but they are frequently 
repeated. Some of them he seems to forget entirely, and 
then new ones are formed. When he speaks quick he some- 
times pronounces numbers, and now and then he employs 
common words in their proper sense. He is conscious that 
he speaks nonsense. What he writes is equally faulty with 
what he speaks. He cannot write his name. The words 
he writes are those he speaks, and they are always written 
conformably to his manner of pronouncing them. He can- 
not read, and yet many external objects seem to awaken in 
him the idea of their presence." 

Dr. Bush, 1 in the work the title of which is cited below, 
in chapter xii., which treats of Derangement in the Mem- 
ory, refers so specifically to affections of the speech that I 
quote his language with some degree of fulness, and I do so 
with the less hesitation as his observations appear to have es- 
caped notice, both in this country and in Europe. He says : 

" 1. There is an oblivion of names and vocables of all 
kinds. 

" 2. There is an oblivion of names and vocables, and a 
substitution of a word no ways related to them. Thus, I 
knew a gentleman afflicted with this disease, who, in calling 
for a knife, asked for a bushel of wheat. 

1 Medical Inquiries and Observations upon Diseases of the Mind. Fourth 
edition. Philadelphia, 1830, p. 274. The first edition was published in 1812. 



172 DISEASES OF THE BRAIN. 

" 3. There is an oblivion of the names of substances in a 
vernacular language, and a facility of calling them by their 
proper names in a dead or foreign language. Of this, 
Wepfer relates three instances. They were all Germans, 
and yet they called the objects around them only by Latin 
names. Dr. Johnson, when dying, forgot the words of the 
Lord's prayer in English, but attempted to repeat them in 
Latin. Delirious persons, from this disease of the memory, 
often addresstheir physicians in Latin or in a foreign tongue, 

" 4. There is an oblivion of all foreign and acquired lan- 
guages, and a recollection only of vernacular language. Dr. 
Scandella, an ingenious Italian, who visited this country a 
few years ago, was master of the Italian, French, and Eng- 
lish languages. In the beginning of the yellow fever which 
terminated his life in the city of New York in the autumn 
of 1798, he spoke English only ; in the middle of his disease 
he spoke French only ; but on the day of his death he spoke 
only in the language of his native country. 

" 5. There is an oblivion of the sound of words, but not 
of the letters which compose them. I have heard of a cler- 
gyman in Newburyport, who, in conversing with his neigh- 
bors, made it a practice to spell every word that he employed 
to convey his ideas to them. 

" 6. There is an oblivion of the mode of spelling the 
most familiar words. I once met with it as a premonitory 
symptom of palsy. It occurs in old people, and extends to 
an inability, in some instances, to remember any more of 
their names than their initial letters. I once saw a will 
subscribed in this way by a man in the eightieth year of 
his age, who during his life always wrote a neat and legible 
hand. 

" 9. There is an oblivion of names and ideas, but not of 
numbers. We had a citizen of Philadelphia many years 
ago, who, in consequence of a slight paralytic disease, forgot 
the names of all his friends, but could designate them cor- 



APHASIA. 173 

rectly by mentioning their ages, with which he had pre- 
viously made himself acquainted." 

Dr. Bush remarks of these cases, that " there appears to 
be something like a palsy of the mind, quoad these specific 
objects." 

Thus far there had been no attempt to define with pre- 
cision the seat of the faculty of language, or even to estab- 
lish its existence ; but, in the early part of the nineteenth 
century, Dr. Gall, a German physician, announced that such 
a faculty did exist, and that it was seated in those convolu- 
tions of the brain which rest upon the posterior part of the 
supra-orbital plate, and that a large development of the or- 
gan was indicated by prominence and depression of the eyes. 
He was first led to believe in the existence of such an organ 
by observing that some of the scholars with whom, as a 
young man, he had to compete, excelled him in the ability 
to learn by heart, and he noticed that those thus endowed 
with great memory for words possessed prominent eyes. 
From these circumstances, he was gradually carried on to 
the foundation of his phrenological system. 

In reality, however, Gall considered that there were two 
organs of language in each hemisphere — the one originat- 
ing the idea of words, the other the talent for philology, and 
for acquiring the spirit of languages. The former organ he 
describes as lying on the posterior half of the snpra-orbital 
plate, as before mentioned. It gives a talent for learning 
and recollecting words, and persons possessing it large re- 
cite long passages by heart after reading them once or 
twice. The other is placed on the middle of the supra-orbi- 
tal plate, and when it is large the eyeball is not only ren- 
dered prominent but is depressed, causing the lower eyelid 
to assume the appearance of a bag or fold. Persons having 
this organ large have not only an excellent memory for 
words, but a particular talent for the study of languages, for 
criticism, and in general terms for all that has reference to 
literature. 



174 DISEASES OF THE BRAIN. 

Dr. Spurzheim, however, admits but one organ, lying 
transversely on the posterior portion of the supra-orbital 
plate, and this view is accepted by Combe and other dis- 
tinguished phrenological authorities. 1 

In support of his theory that there is such an organ, 
Gall cites the case of a notary reported by Pinel. 2 The 
latter, in speaking of apoplexy, says this affection may be 
limited in its action to the words which are used to express 
ideas. In the case mentioned, the patient forgot, after an 
attack of apoplexy, his own name, that of his wife, those of 
his children and friends, although there was not the least 
paralysis of his tongue. He no longer knew how to read or 
write, and yet his memory as regarded other things was un- 
impaired. 

Dr. Gall 3 refers also to the case of a soldier, sent to him 
by Baron Larrey, who was affected in a manner similar to 
that of the notary. It was not his tongue which was in- 
volved, for he was able to move it about in all directions, 
and to pronounce words, but he had lost the memory for 
words, although he recollected other things as well as ever. 

I shall presently have occasion to refer to a still more 
interesting case, reported by Larrey, and one which appears 
to have escaped the notice of all writers on the subject of 
aphasia. 

Spurzheim mentions the case of one Lereard, of Mar- 
seilles, who, having received a blow from a foil on the eye- 
brow (which one is not stated), lost the memory of proper 
names entirely. He sometimes even forgot the names of his 
intimate friends, and even of his father. 

Gall, therefore, located the organ of language in a limited 

1 For a full account of the subject, the reader is referred to a System of 
Phrenology, by George Combe, Boston, 1834, or to Phrenology, etc., by J. S. 
Spurzheim, Boston, 1833. 

2 Traite Medico-Philosophique, sur l'alienation mentale. Second edition. 
Paris, 1809, p. 90. 

3 Physiologie du cerveau, vol. iv., p. 84. 



APHASIA. 175 

part of the anterior lobe of each hemisphere ; but he ad- 
duced very little evidence to support his opinion, and hence 
his views did not meet with any thing like general accept- 
ance. A number of cases, however, reported by Lallemand, 
Rostan, and others, support it, while several adduced by 
the same authors are opposed to it. 

In 1825 Bouillaud, 1 who had collected a great number 
of cases of affections of the brain, was surprised to find how 
frequently the loss of speech coexisted with disease or injury 
of the anterior lobes. He also confirmed, what others before 
him had noticed, that the loss of the power of expressing 
ideas in articulate language was often the only evidence of 
a brain-affection. 

He made one very important step in advance, and his 
views on this particular point are adopted — and often with- 
out credit — by the majority of the present writers on apha- 
sia : he divided the faculty of speech into two distinct cate- 
gories of phenomena : 

1. The faculty of creating words as representatives of 
our ideas, and of recollecting them — internal speech. 

2. The power of coordinating the movements necessary 
for the articulation of these words — external speech. 

This classification forms the basis of the division of 
aphasia into the two varieties, the amnesic and the ataxic. 

The cases which Bouillaud adduced in support of his 
theory were many of them in patients who exhibited no 
other symptoms than the loss of the power of articulate 
language. They preserved their intelligence, comprehended 
perfectly questions put to them, and knew the value of 
words ; but, although there was no paralysis of either the 
tongue or the lips, they were unable to utter a word. At 
the post-mortem examination, the lesion was always found 
in the anterior lobes. Sixty-four cases formed the basis of 

1 Traite de Fencephalite, Paris, 1825 ; and also, Kecherches cliniques, pro- 
pres a demontrer que la perte de la parole correspond a la lesion des lobules 
anterieurs du cerveau, Archives de Med., 1825. 



176 DISEASES OF THE BRAIN. 

his conclusions. A part were direct, and went to show that 
lesion of the anterior lobes was accompanied by derange- 
ment in the faculty of speech ; the other part were indirect, 
and established the fact that, when the anterior lobes were 
not affected, the lesion being in some other region of the 
brain, the faculty of speech remained intact. 

Cruveilhier opposed Bouillaud's views, and, in a paper 
read at the Athenee de Medecine in the same year, brought 
forward seven cases of persons, some of whom had lost the 
faculty of speech, but who, on post-mortem examination, 
were found to have no disease of the anterior lobes ; and 
others who had spoken, but in whom there were more or 
less profound changes in these parts. 

Subsequently Andral * reported the results of the analy- 
sis of thirty-seven cases of lesion of one or both anterior 
lobes. Of these, speech was abolished twenty-one times, 
and preserved sixteen times. Lallemand 2 also opposed Bou- 
illaud with several cases ; but the latter rejoined 3 with a 
fresh array of thirteen cases in support of his doctrine, and 
with many arguments against the validity of those brought 
against him. Longet 4 declares that Bouillaud appears to 
have refuted many of the objections of his adversaries, and 
to have demonstrated that some of their cases were badly 
interpreted. At the same time, while admitting that it is 
possible that different parts of the brain preside over differ- 
ent voluntary movements, he affirms that there is nothing 
positively established as regards the localization of the ac- 
tive principles of these movements. 

Subsequently, in other memoirs, Bouillaud brought for- 
ward additional cases in support of his theory, making a 

1 Clinique Medicale, t. ii., p. 135. 

2 Op. cit, lettres 6, 7, 8. 

3 Exposition de nouveaux faits a l'appui de l'opinion qui localise dans les 
lobes anterieurs du cerveau le principe legislateur de la parole. Bulletin de 
TAcademie de Medecine, 1839, torn, iv., p. 282. 

4 Traite de la Physiologie, t. ii., p. 438. 



APHASIA. 177 

total of one hundred and three, and offered a prize of five 
hundred francs to any one who would adduce an instance 
of profound lesion of the anterior lobes without troubles of 
speech. Many years subsequently Velpeau announced that 
lie should claim this prize, for that, in March, 1843, he had 
related the case, and presented the brain, of a wig-maker 
who had come under his care for prostatic disease. This 
man was in full possession of his reasoning faculties, and, 
moreover, was noted for his unconquerable loquacity. He 
died a few days subsequently, and on post-mortem examina- 
tion a scirrhous tumor was found to have entirely taken the 
place of the two anterior lobes of the brain. Yery little 
faith seems to have been put by physiologists or pathologists 
in the history of this case. If it proves any thing, it is that 
the anterior lobes are useless appendages to the rest of the 
cerebral system. 

But Bouillaud was not content with the deductions to 
be drawn from pathology. In a series of experiments, he 
endeavored to establish the truth of his idea, and thus bring 
the science of physiology to his support. These experi- 
ments were detailed in a paper l read before the Academy 
of Sciences, in September, 1827, which was subsequently 
(1830) published in the tenth volume of Magendie's Journal 
de Physiologie, from which I quote. 

The experiments relative to the anterior lobes were made 
on dogs. Only one was entirely successful — the animals in 
the others dying too soon after to admit of satisfactory de- 
ductions being made. But the twentieth experiment was 
more satisfactory. 

On the 28th of June, 1826, he passed a gimlet through 
the anterior part of the brain of an active, docile, and intel- 
ligent dog. Immediately afterward the animal was con- 
vulsed, and could not rise from the ground. Sight and 
hearing remained. Symptoms of compression soon came on ; 

1 Recherches experimentales sur les fonctions du cerveau (lobes cerebraux) en 
general et sur celles de sa portion anterieure en particulier. 
12 



178 DISEASES OF THE BRAIN. 

the result, probably, of the haemorrhage. Eventually, the 
animal recovered, but it was found to have lost much of its 
intelligence and agility. The faculty of memory seemed to 
have been entirely abolished, and there was a decided expres- 
sion of imbecility in its countenance. It could no longer 
ascend or descend a staircase ; the fore-legs were lifted very 
high in walking, and its movements were all badly coordi- 
nated. When struck or made to walk, it uttered sharp 
cries, but it had lost entirely the ability to bark. As Bou- 
illaud remarks, " it no longer barked, either to show its 
affection, or to drive away strangers who came to the house." 
Once only, on the 18th of July, it tried to bark at a passer- 
by, but failed in the attempt. 

This is the only experiment I have been able to find 
which has any bearing upon the question of the localization 
of the faculty of language. And I do not quote it as prov- 
ing much on the subject. The difficulties in the way of 
experimentation are almost insuperable, to say nothing of 
the fact that it is doubtful if any of the sounds made by 
animals can be compared with human speech. 

But unintentional experiments have been performed 
upon the human subject, which tend to show that, though 
the faculty of language may be located in one or both an- 
terior lobes, either may be seriously injured without the 
faculty of language suffering to any appreciable extent. 
Two of them have happened in this country, and, although 
referred to in connection with aphasia by Seguin and Har- 
ris, I take great satisfaction in bringing them forward on 
account of their great importance to the question under 
consideration. 

The first is related by Dr. Harlow, 1 of Yermont : 

The subject was a strong, healthy man, twenty-five years 
of age, and was engaged in ramming down a charge of 

1 Boston Medical and Surgical Journal, December, 1849, vol. xxxix., p. 389. 
Also Descriptive Catalogue of the Warren Anatomical Museum. Boston, 1870, 
p. 145. 



APHASIA. 179 

powder in a rock to be blasted, when an explosion took 
place, and the t ampin g-ir on was driven clear through his 
head. 

In a few minutes he recovered his consciousness, was 
put into a cart and carried three-quarters of a mile to his 
residence, where he got out and walked into the house. 
Two hours afterward he was seen by Dr. Harlow. He was 
then quite conscious and collected in his mind, but ex- 
hausted by extensive haemorrhage from the hole in the top 
of his head. Blood, pus, and particles of brain, continued to 
be discharged for several days, but by January 1, 1849, the 
wound was quite closed and his recovery complete. There 
was no pain in the head, but a queer feeling, which he could 
not describe. As regarded his mind, he was fitful and va- 
cillating, though obstinate, as he had always been. He be- 
came very profane, never having been so before the accident. 
He lived till May 21, 1861, twelve and a half years subse- 
quent to the accident, when he died, after having had several 
convulsions. His cranium was obtained, and, with the bar, 
is now preserved in the "Warren Anatomical Museum at 
Boston. Dr. J. B. S. Jackson x thus describes the skull : 

" The whole of the small wing of the sphenoid bone 
upon the left side is gone, with a large portion of the large 
wing, and a large portion of the orbital process of the frontal 
bone, leaving an opening in the base of the skull two inches 
in length, one inch in width posteriorly, and tapering gradu- 
ally and irregularly to a point anteriorly. This opening 
extends from the sphenoidal fissure to the situation of the 
frontal sinus, and its centre is an inch from the median line. 
The optic foramen and the foramen rotundum are intact. 
Below the base of the skull the whole posterior portion of 
the upper maxillary bone is gone. The malar bone is un- 
injured ; but it has been very perceptibly forced outward, 
and the external surface inclines somewhat outward from 
above downward. The lower jaw is also uninjured. The 

1 Descriptive Catalogue of Warren Anatomical Museum, loc. cit. 



180 DISEASES OF THE BRAIN. 

opening in the base, above described, is continuous with a 
line of old and united fracture that extends through the 
supra-orbitary ridge in the situation of the foramen, inclines 
toward and then from the median line, and terminates in 
an extensive fracture that was caused by the bar as it came 
out through the top of the head. This fracture is situated 
in the left half of the frontal bone, but inferiorly it extends 
somewhat over the median line. In form it is about quadri- 
lateral ; but it measures two and a half by one and three-quar- 
ter inches. Two large pieces of bone are seen to have been 
detached and upraised, the upper one having been separated 
at the coronal suture from the parietal bone, and being so 
closely united that the fracture does not show upon the 
outer surface. The lower piece shows the line of fracture 
all around. Owing to the loss of bone, two openings are 
left in the skull ; one that separates the two fragments has 
nearly a triangular form, extends rather across the median 
line, and is four inches in circumference ; the other, situated 
between the lower fragment and the left half of the frontal 
bone, is long and irregularly narrow, and is two and five- 
eighths inches in circumference. The edges of the fractured 
bones are smooth, and there is nowhere any new deposit." 

From this account it will be seen that the left anterior 
lobe of the brain suffered severely by this terrible injury, and 
yet it is not stated that the subject had ever shown any dif- 
ficulties of speech. If the faculty of language resides in the 
whole of the lobe, such an immunity could scarcely have 
existed. It must be noted, however, and the photograph 
of the cranium establishes the fact, that the third frontal 
convolution and the island of Keil escaped all injury. An- 
other interesting circumstance is the addiction to profanity 
after the accident. A like phenomenon has been noticed in 
cases of aphasia. 

The second instance is almost as extraordinary. I quote 
the history of the case, 952, from Dr. Jackson : x 

1 Op. cit., p. 149 



APHASIA. 181 

" Cast of the head of a man who was transfixed through 
the head by an iron gas-pipe, and who, to a very considerable 
extent, recovered from the accident. 

" The patient, a healthy and intelligent man, abont twen- 
ty-seven years of age, was blasting coal when the charge 
exploded unexpectedly, and the pipe was driven through 
his head, entering at the junction of the middle and outer 
thirds of the right supraorbitary ridge, and emerging near 
the junction of the left parietal, occipital, and temporal bones. 
One of his fellow-miners saw him upon his hands and knees, 
and struggling as if to rise; and, going to his assistance, he 
placed his knee upon his chest, supported his head with one 
hand and with the other withdrew the pipe. This last pro- 
jected about equally from the front and back of the head, 
and much force was required for its withdrawal." 

Brain escaped from the anterior opening, and coma and 
collapse supervened. " In seven weeks he sat up, and in 
one more walked about. The right hand he used somewhat, 
but less well than the left. For about ten months after the 
accident his memory for some things was nearly lost, but 
during the next two months there was a considerable im- 
provement." 

The accident happened on May 14, 1867, and in June, 
1868, the patient, with the gas-pipe, was exhibited to the 
Massachusetts Medical Society. " The man appeared to be 
in a good state of general health ; and, though his mental 
powers were considerably impaired, there was nothing un- 
usual in his expression, nor would there be noticed, in a few 
minutes' conversation with him, any marked deficiency of 
intellect." 

It is very evident that in this case the right anterior lobe 
was seriously injured — the left escaping — and yet there 
does not appear to have been any aberration of speech. It 
is to be regretted, however, that the history is not more 
specific as to the things in regard to which the memory was 
deficient. 



182 DISEASES OF THE BKAIN. 

There are other cases which militate against Bouillaud's 
doctrine. Thus, M. Peter 1 states that a drunken cavalry- 
soldier fell from his horse on the back of his head, and frac- 
tured his skull. Stupor set in at once, followed by the most 
violent delirium. The man kept constantly shouting the 
worst possible oaths, and held connected conversations with 
imaginary persons. He died at the end of thirty-six hours, 
without having recovered his reason. On dissection, a frac- 
ture of the roof and base of the skull was found in all its 
length. The posterior lobes of the brain were found, on 
post-mortem examination, to have sustained no injury, but 
both anterior lobes were in a pulpy condition, through a 
most violent contusion, caused by their being knocked 
against the anterior wall of the cranium. The whole thick- 
ness of the lobes was disorganized. As Trousseau remarks, 
this case shows that the two frontal lobes may be destroyed 
in their anterior portion without causing a loss of the faculty 
of speech. Trousseau also cites the case of two officers, 
who, after a quarrel, fought a duel. One of them fired first, 
and the ball entered his adversary's head at one temple, 
passed through the brain, and then raised the temporal bone 
on the opposite side. The ball was extracted, and the pa- 
tient immediately made a sign with his hands, and expressed 
his thanks in a very low voice. He recovered, for the time 
being, and, during iive months thereafter, could speak per- 
fectly well, and was remarkable for the wit and fluency of 
his conversation and writing. He subsequently died of 
softening; and it was found, on post-mortem examination, 
that the ball had passed through the two frontal lobes in 
their middle portion. A still more striking case is referred 
to by Dr. Bazire, in a note to Trousseau's lecture on apha- 
sia, in the work cited. It was reported in 1843 by M. 
Aug. Berard, to the Anatomical Society of Paris. The pa- 
tient, a miner, was knocked down and severely injured by 

1 Quoted by Trousseau, Lectures on Clinical Medicine. Translated by Ba- 
zire, vol. i., p. 256. 



APHASIA. 183 

an explosion in a mine. He did not lose consciousness, but 
managed to creep out of his hole and to call to his help some 
men who were working a short distance off. He begged 
them to fetch a cart and to take him to M. Berard's house. 
He was there examined. The whole frontal region was laid 
open, the integuments hung in shreds, the bones were splin- 
tered and in detached fragments, and the brain was exposed. 
Both anterior cerebral lobes were completely destroyed, and 
in their stead was a mixture of blood, of bony splinters, and 
brain-substance. In spite of this frightful injury the man 
could relate in all its details how the accident had occurred. 
He died the next day. 

Whether or not we accept this case in all the import 
claimed for it, there can be no doubt that Bouillaud is wrong 
in claiming that injury of the anterior lobes is necessarily 
followed by some derangement in the faculty of speech. It 
is only fair, however, to state that latterly he has admitted 
that the organ of language may occupy the posterior part 
of either lobe. 

Dr. M. Dax, in 1836, read a paper before the medical 
congress which met that year at Montpellier, in which he 
came to the conclusion that the faculty of language " was 
seated, not as Gall and Bouillaud had contended, in both 
anterior lobes of the brain, but that it occupied only the left 
anterior lobe." He based this opinion on one hundred and 
forty cases of aphasia attended with paralysis, and in which 
the loss of power was on the right side ; showing, therefore, 
that the lesion which produced the aberration of speech also 
caused the hemiplegia, and that this lesion must have been 
on the left side. This paper at the time attracted very little 
attention, and was forgotten till the year 1861 witnessed 
the reopening of the discussion. 1 

It would be very easy to quote a large number of cases 
confirmatory of Dr. Dax's doctrine, but a few will suffice to 

1 Dr. Marc Dax's Memoir was republished in the Gazette Hebdomadaire, No. 
17, April, 1865. 



184 DISEASES OF THE BRAIN. 

show the general bearing of a great many others. The fol- 
lowing case seems to have escaped notice. It is not the one 
referred to by Gall as being sent to him by Larrey. In that 
case the left anterior lobe was injured and there was aphasia, 
but the lesion was caused by a sword. 

Baron Larrey * presented to the Academy the cranium 
of a subject, with the following history : 

Toward the end of the year 1815 an officer of dragoons 
came to the hospital with a wound from a ball which he had 
received at Waterloo. The missile had entered the left side 
of the cranium at a point about six or eight millimetres 
from the eyebrow and near the temporal ridge. At first he 
had suffered loss of consciousness and profuse haemorrhage, 
but had recovered, with but slight loss of motor power. So 
far as his mind was concerned, there was no derangement 
except as regarded the faculty of speech ; he had lost the 
memory of substantives. For this reason he was unable to 
drill his company, and, though able to distinguish his men 
by their size, their form, their complexion, or their voice, he 
could not call them by name. He refused to allow the 
operation of trephining to be performed, and in 1827 died 
of phthisis. 

A post-mortem examination was made. The ball was 
found embedded in the thickness of the bone, having ele- 
vated and fractured the internal table. The dura mater 
was strongly adherent to the whole of the left anterior cra- 
nial fossa ; it was also thicker and denser than in the natural 
state. A spheroidal excavation, five centimetres in its hori- 
zontal and seven or eight in its vertical diameter, was dis- 
covered at the summit and on the temporal side of the left 
anterior lobe of the brain. 

Mr. Thomas Hood 2 reported the history of a patient, a 

1 Blessure du Cerveau avec perte de Memoire des Noms Substantives. Jour- 
nal de Physiologie de Majendie, t. viii., 1828, p. 1. 

2 Phrenological Transactions. Quoted by George Combe in his System of 
Phrenology, Boston, 1834, p. 429. 



APHASIA. 185 

sober, intelligent man, sixty years of age, who, on the even- 
ing of September 2, 1822, suddenly began to speak incohe- 
rently, and became quite unintelligible to those around him. 
It was discovered that he had forgotten the name of every 
object in Nature. His recollection of things seemed to be un- 
impaired, but the names by which men and things were 
known were entirely obliterated from his mind, or rather he 
had lost the faculty by which they were called up at the con- 
trol of the will. He was by no means inattentive, however, 
to what was going on, and he recognized friends and ac- 
quaintances perhaps as quickly as on any former occasion ; 
but their names, or even his own or his wife's name, or the 
names of any of his domestics, appeared to have no place in 
his recollection. 

" On the morning of the 4th of September," says Mr. 
Hood, " much against the wishes of his family, he put on 
his clothes and went out to the workshop, and when I made 
my visit he gave me to understand, by a variety of signs, 
that he was perfectly well in every respect, with the excep- 
tion of some slight sensations referable to the eyes and eye- 
brows. I prevailed on him with some difficulty to submit 
to the reapplication of leeches, and to allow a blister to be 
placed over the left temple. He was now so well in bodily 
health that he would not be confined to the house, and his 
judgment, in so far as I could form an estimate of it, was 
unimpaired, but his memory of words was so much a blank, 
that the monosyllables of affirmation and negation seemed to 
be the only two words in the language the use and signifi- 
cation of which he never entirely forgot. He comprehended 
distinctly every word which was spoken or addressed to him ; 
and, though he had ideas adequate to form a full reply, the 
words by which these ideas are expressed seemed to have 
been entirely obliterated from his mind. By way of experi- 
ment I would sometimes mention to him the name of a 
person or thing, his own name for example, or the name 
of some one of his domestics, when he would repeat it 



186 DISEASES OF THE BRAIN. 

after me distinctly once or twice ; but generally before he 
could do so a third time the word was gone from him as 
completely as if he had never heard it pronounced. "When 
any person read to him from a book, he had no difficulty in 
perceiving the meaning of the passage, but he could not 
himself then read, and the reason seemed to be that he had 
forgotten the elements of written language, viz., the names 
of the letters of the alphabet. In the course of a short time 
he became very expert in the use of signs, and his convales- 
cence was marked by his imperceptibly acquiring some gen- 
eral terms which were with him, at first, of very extensive 
and varied application. In the progress of his recovery, 
time and space came both under the general application of 
time. All future events and objects before him were, as he 
expressed it, ' next time ; ' but past events and objects be- 
hind him were designated 'last time? One day, being 
asked his age, he made me to understand that he could not 
tell ; but, pointing to his wife, uttered the words, ' many 
times J repeatedly, as much as to say that he had often told 
her his age. When she answered sixty, he answered in the 
affirmative." 

On the 10th of January he suddenly became paralytic 
on the left side [this is evidently a typographical error for 
right side]. On the 17th of August he had an attack of 
apoplexy, and on the 21st he expired. In the Phrenologi- 
cal Journal, vol. iii., p. 28, Mr. Hood has reported the dis- 
section of his brain : " In the left hemisphere, lesion of the 
parts was found, which terminated at half an inch from the 
surface of the brain, where it rests on the middle of the su- 
pra-orbital plate." Two small depressions or cysts were 
found in the substance of the brain, " and the cavity consid- 
ered as a whole expanded from the anterior part of the brain 
till it opened into the ventricle in the form of a trumpet. 
The right hemisphere did not present any remarkable ap- 
pearance." 



APHASIA. 187 

The late Dr. Thomas Hun 1 , of Albany, in detailing a 
case of amnesia in which there were no symptoms of paral- 
ysis, and in which there was no post-mortem examination, 
cites the case of a lady who died of cancer of the brain, oc- 
cupying, at the time of her death, the greater portion of the 
left anterior lobe. In the early stages of her disease she 
was often unable to call the most familiar objects by name, 
and had to express herself by signs or by pointing at the ob- 
ject. When the word she wanted was pronounced before 
her, she recognized it, and was able to repeat it. 

Other cases, and especially several which have occurred 
in my own experience, are reserved for future consideration. 

Up to this period we have the organ of articulate lan- 
guage limited to the left anterior lobe of the brain, but in 
1861 its location was still further restricted. In that year 
M. Gratiolet, in discussing before the Anthropological So- 
ciety of Paris a question relative to the comparative devel- 
opment of the brain and mind among different races, brought 
up the subject of cerebral localization, to which he announced 
himself as being strongly opposed. M. Auburtin, on the 
contrary, contended that the localization of the faculty of 
speech at least was definitely established, through the re- 
searches of Bouillaud, in the anterior lobes. In support of 
this view, he adduced cases which had already been brought 
forward, and cited others in addition, which went to show 
that loss of speech was the consequence of traumatic lesion 
of these parts of the brain. His adversaries cited other cases 
in which persons had preserved the faculty of language not- 
withstanding extensive lesions of the anterior lobes. M. 
Auburtin responded that, if such profound and extensive in- 
juries had not interfered with speech, it was because that 
part of the lobes in which the organ is situated was not in- 
volved. And he then cited the case of a patient in the Hos- 
pital for Incurables, who for many years had been deprived 
of the power of speech, and he declared that he would re- 

1 American Journal of Insanity, vol. vii., 1850-51, p. 359. 



188 DISEASES OF THE BRAIN. 

nounce the doctrine of Bouillaud if the autopsy of this patient 
did not reyeal disease of the anterior lobes. The patient in 
question was under the charge of ~M. Broca, and the latter, a 
decided opponent, accepted the challenge of M. Auburtin, 
and declared that, when the man died, the examination 
should be made. 

Some time afterward the patient died, the post-mortem 
examination was made, and the lesion was found to occupy 
the left anterior lobe. 1 

From this time forward, M. Broca, who had been a most 
determined opponent of Bouillaud's views of localization, 
became converted, and carried them to a still more extreme 
point than even M. Marc Dax had done. Taking, as his 
principal case, the one to which M. Auburtin had pinned his 
faith, he read, in 1861, before the Anatomical Society of 
Paris, a memoir, 2 in which he discusses the question of the 
location of the faculty in question with all his perspicuity 
and directness. As the two cases cited by him are of his- 
torical interest, I give the chief details of them : 

A man named Le Borgne, who had been an inmate of 
another department of Bicetre for over twenty years, was 
transferred to one of the wards under M. Broca's care, to 
be treated for a severe attack of phlegmonous erysipelas. 
The man was a confirmed epileptic, and had not spoken, 
since his entrance into the hospital, more than a few words, 
which he employed for the expression of all his ideas. It 
is stated that in other respects his intelligence was good. 
Le Borgne was known in the hospital by the name of " Tan," 
a word which he habitually used, and which, with the oath, 
" Sacre nom de Dieu" constituted his entire vocabulary. 
" Tan," owing to the constancy with which he used it, was 
the name by which he was known in the hospital ; and, when 

1 See Etude sur la localisation de la Faculte du Langage Articule. These 
de Paris de M. Carrier, 1867. 

2 Sur le siege de la faculte de langage articule avec deux observations 
d'aphemie. Bull, de la Soc. Anatomique, t. iv., 1861. 



APHASIA. 189 

lie could not make himself understood by his signs, he em- 
ployed the oath, and gave other manifestations of anger. 

For several years he had remained in the hospital with 
no other lesion than that of speech, with an occasional 
epileptic paroxysm ; but, after a few years, his right arm 
became paralyzed, and four years subsequently the leg of 
the same side was involved ; his sight was likewise enfee- 
bled, and for the past seven years he had been entirely con- 
fined to his bed. 

Notwithstanding the fact that he was almost in a dying 
condition when M. Broca first saw him, some important 
points in his cerebral difficulty were noted. To any ques- 
tion put to him, he replied, as usual, " Tan" but at the same 
time endeavored to make himself understood by signs. 
Thus he raised six lingers to indicate that six days had 
elapsed since the inception of his erysipelas, and by opening 
and shutting his hand four times and then raising one finger 
signified that he had been twenty-one years in Bicetre. 

Sensibility was lessened on the affected side ; there was 
no deviation of the tongue, which could be moved freely in 
all directions, and no paralysis of the face beyond a slight 
weakness shown by the swelling of the left side when he 
breathed ; there was a little difficulty of swallowing, from 
the fact that the muscles of the pharynx were gradually be- 
coming implicated. 

After a few days the man died. 

As I have said, the autopsy showed that the lesion was 
situated in the left anterior lobe. More exactly, however, 
it should now be stated that it involved the inferior margi- 
nal convolution of the temporo-sphenoidal lobe, the convo- 
lutions of the island of Rett, and in the frontal lobe, the 
frontal transverse convolution, and the posterior half of the 
second and third frontal convolutions. The left corpus stria- 
tum was also affected. According to Broca, the disease had 
in all probability begun in the third frontal convolution, 
and had gradually extended to the other parts ; the paraly- 



190 DISEASES OF THE BRAIN. 

sis marking the implication of the island of Eeil and the 
corpus striatum. 

The other case was that of a man named Le Long, aged 
eighty-four years, who had entered the hospital for a frac- 
ture of the neck of the femur. Eighteen months before, he 
had been treated in the medical service for a temporary 
apoplexy, which had deprived him of the faculty of speech, 
but had caused no paralysis. Le Long, whose intelligence, 
facial expression, and ability to gesticulate, were very strik- 
ing, made himself perfectly well understood, although able 
to pronounce indistinctly a very few words, but which were 
nevertheless properly applied. These words were "oui" 
" non, toujours, tois " for trois, and Lelo for Le Long. Thus, 
when asked, " Can you write \ " he answered, " Oui." 
" Have you any children ? " "Oui." "How many? "Tois," 
but at the same time, as if aware that he was not answer- 
ing correctly, he raised four fingers. " How many boys ? " 
" Tois," raising two fingers. " How many girls ? " " Tois," 
holding up two fingers. " What time is it by this watch % " 
" Tois," at the same time raising ten fingers to signify that 
it was ten o'clock. " How old are you ? " To this question 
he replied by two gestures ; the one consisting of raising 
eight fingers, the other of four fingers, by which he meant 
that he was eighty-four years old. 

Aside from this application of the word tois to all num- 
bers, his answers were perfectly correct. The tongue was 
neither paralyzed nor thickened ; on one side the larynx was 
mobile, and his limbs possessed their normal power for his 
age. It was therefore a case of pure aphasia, or, as Broca 
then designated the affection, aphemia. 

Twelve days after the accident, the patient died. The 
post-mortem examination revealed the existence of lesions, 
almost identical in situation with those of the former case. 
The posterior part of the third left frontal convolution, and 
the contiguous part of the second, had been absorbed and 
replaced by a serous fluid. Two cases can scarcely decide 



APHASIA. 191 

any point in pathology ; but, without venturing to assert posi- 
tively that the organ of language resides exclusively in the 
posterior part of the third frontal convolution, M. Broca 
expressed the opinion that the integrity of this convolution, 
and perhaps of the second, is indispensable to the normal 
operation of the function of speech. 

Many cases were adduced by Charcot, 1 by Falret, 8 by 
Perroud 3 of Lyons, by Trousseau, 4 and others, in support of 
the localization of the faculty of articulate language in the 
left side of the brain. Most of these cases were accom- 
panied by right hemiplegia, and, in several, post-mortem 
examinations showed the lesion to exist in the parts desig- 
nated by Broca. 

In the early part of 1863, M. G. Dax, son of the M. Dax 
who had placed the organ of language in the left hemi- 
sphere, presented, through M. Lelut, a memoir to the Acad- 
emy, in which he claimed with his father that aphasia was 
always the result of lesion of the left hemisphere, but he as- 
signed a still more restricted position, by limiting it to the 
anterior and exterior part of the middle lobe. He cited 
forty cases of loss of the power of speech, coincident with 
lesion of the left hemisphere. 

Now, besides these direct cases, there are others which 
bear with almost as much effect on the affirmative of the 
doctrine in question. Thus M. Fernet, in 1863, presented a 
case to the Societe de Biologie, in which there was left 
hemiplegia, but no aphasia. After death, softening of the 
right hemisphere, from thrombosis of the right middle cere- 
bral artery, was found to exist. M. Parrot 6 adduced another 
case in which there was complete atrophy of the island of 
Eeil, and of the third convolution of the right side, but in 
which there was no trouble of speech. These cases go to 

1 Gazette Hebdom., 1863, pp. 473, 525. 

2 Archives de Med., t. iv., Mars et Mai, 1864. 

3 Journal de Med. de Lyon. Jan. et Fev., 1864. 

4 Chnique Medicale. 5 Gazette Hebdom., 1863, p. 506. 



192 DISEASES OF THE BRAIN. 

show that the organ of articulate language is not situated in 
the right hemisphere. 

M. Lesur 1 has reported a case which is of very great 
interest. A child was kicked on the head by a horse, and a 
fracture of the frontal bone was thus produced. The opera- 
tion of trephining was performed at a point about an inch 
and a quarter above the left eye. After the operation and 
during the progress of the case, it was observed that, when- 
ever pressure was made upon the brain through the hole in 
the cranium, the child lost the power of speech, and that 
when this pressure was removed she regained it. A similar 
case occured several years ago in my own practice. 

Among British writers, Dr. Hughlings Jackson 8 has 
given the histories of thirty-four cases of loss of speech co- 
inciding with right hemiplegia. He is entitled to the credit 
of making a beautiful application of anatomy and physi- 
ology to the pathology of the subject under consideration. 
The part of the brain designated by Broca as the seat of 
the organ of articulate language is nourished by the left 
middle cerebral artery. An obstruction of this artery would 
of course interfere with the perfect action of that region, 
and thus aberrations of speech would be produced. But 
the same artery also supplies blood to the corpus striatum 
of the same side. Hence the frequency with which aphasia 
is associated with right hemiplegia. The cause of the ob- 
struction is generally, according to Dr. Jackson, embolism, 
for in twenty of his cases the heart was more or less affect- 
ed, and in thirteen of them there was valvular disease. 

Among other British writers, some of whom will be more 
fully referred to hereafter, must be mentioned, Dr. Sanders, 3 
Dr. Moxon, 4 Dr. Ogle, 6 Dr. Bateman, 6 and Dr. Bastian. 7 

1 Gazette des Hopitaux. 2 London Hospital Reports, vol. i. 

3 Edinburgh Medical Journal, August, 1866. 

4 British and Foreign Medieo-Chirurgical Review, April, 1866. 

5 St. George's Hospital Reports, vol. h\, 1867. 

6 Journal of Mental Science, January, 1868, and subsequent numbers. 

7 British and Foreign Medieo-Chirurgical Review, January and April, 1869. 



APHASIA. 193 

The matter does not appear to have attracted much at- 
tention from German physiologists and pathologists, since 
the discussion in the French Academy in 1861. Previous 
to that period several excellent memoirs upon the physi- 
ology of speech were published by Germans, among which 
that of Dr. Bergman 1 is preeminent. A memoir by Nasse 2 
is also interesting. 

In 1865 Yon Benedict, and Braunwart 3 published a 
very thorough paper on the subject, and other observers 
have reported cases. 

In this country there have been several very excellent 
memoirs upon aphasia, and, as we have already seen, the 
subject early attracted attention, and the fact that such a 
condition could exist without other manifest symptoms was 
fully recognized. Thus, Prof. A. Flint 4 detailed the histo- 
ries of six cases, in one of which post-mortem examination 
showed extensive disease of the left anterior lobe, and in 
four, in which the situation of the hemiplegia was noted, the 
right was the affected side. 

Dr. H. B. Wilbur, 5 in a memoir on aphasia, treats of 
the aberrations of the faculty of language as they existed in 
certain idiots under his observation. His cases, though in- 
teresting, are scarcely in point, as the difficulties of speech 
were clearly the result of mental deficiencies. 

A very important memoir is that of Dr. E. C. Seguin, 6 
in which a very excellent history of the subject is given, 
with the citation of forty-eight cases from the records of the 
New York Hospital, in which there were difficulties of 
speech coexisting with hemiplegia, and two in which there 
was no hemiplegia. In several of these cases, however, 

1 Einige Bemerkungen uber Storungen des Gedachtniss und der Sprache. 
Allgemeine Zeitschrift fur Psychiatrie, 1849, s. 657. 

2 All. Zeitschrift, u. s. w., 1853, s. 523. 

3 Canstatt's Jahresbericht, 1865, s. 31. 

4 Medical Record (New York), March 1, 1866. 

5 American Journal of Insanity, July, 1867. 

6 Quarterly Journal of Psychological Medicine, etc., January, 1868. 

13 



194: DISEASES OF THE BRAIN. 

as Dr. Seguin states, the loss of the faculty of speech was 
due to paralysis of the tongue and other muscles concerned 
in articulation. 

Another excellent paper is by Dr. T. "W. Fisher, 1 of Eos- 
ton. Dr. Fisher has studied the subject very philosophi- 
cally, and records thirty-eight cases in which post-mortem 
examinations were made with definite results. Cases have 
also been published by Bartholow a and others. 

With this outline statement of the history of the subject 
of aphasia, we are in a position to inquire more fully into 
the evidence which locates the organ of language in a par- 
ticular region of the brain. 

A clear idea of the anatomy of the parts fixed upon lat- 
terly as the seat of the faculty will aid in the understanding 
of the subject. 

The following account is condensed by Dr. Bateman 3 
from Broca's description in his essay " Sur le Siege de la 
Faculte du Langage articule : " 

" The anterior lobe of the brain comprises all that part 
of the hemisphere situated above the fissure of Sylvius, 
which separates it from the temporo-sphenoidal lobe and 
in front of the furrow of Rolando which divides it from the 
parietal lobe. The furrow of Rolando separates the frontal 
from the parietal lobe ; it traverses from above downward 
all the external surface of the cerebral hemisphere, starting 
from the inter-hemispheric median fissure, and ending at 
the fissure of Sylvius. In front, this furrow is bounded by 
the transverse frontal convolution, and behind by the trans- 
verse parietal convolution. The anterior lobe is composed 
of two stories or divisions — one inferior or orbital, the other 
superior — situated beneath the frontal and under the most 
anterior part of the parietal. This superior division of the 
anterior lobe is composed of four fundamental convolutions ; 

1 Boston Medical and Surgical Journal, September 1, 1870, and subsequent 
numbers. 

2 Medical Repertory, Cincinnati, January, 1869. 3 Op. cit., p. 522. 



APHASIA. 195 

one posterior, the others anterior. The posterior is that 
which has been described as the transverse frontal, and 
which forms the anterior border of the furrow of Kolando ; 
the three other convolutions have all an antero-posterior 
direction, and are distinguished by the names of superior 
or first frontal, middle or second, and inferior or third 
frontal convolutions. This last, by its posterior half, forms 
the superior border of the fissure of Sylvius, the inferior 
border being formed by the superior convolution of the 
temporo-sphenoiclal lobe. In drawing asunder these two 
convolutions which bound the fissure of Sylvius, the lobe 
of the insula (the island of Reil) is exposed, which covers 

Fig. 6. 




FROM BROCA, AS MODIFIED BY DR. HTJGHMNGS JACKSON. 

1. First Frontal Convolution; 2. Second Frontal Convolution ; 3. Third Frontal Con- 
volution ; O. Orbital Convolutions ; E F. Transverse Frontal Convolution ; P. 
Parietal Lobe; T S. Temporo-sphenoidal Lobe; T 1. First Temporo-sphenoidal 
Convolution; T 2. Second Temporo-sphenoidal Convolution; I. Island of Rcil; 
R R. Furrow of Rolando;. S. Fissure of Sylvius. 

the extra ventricular nucleus of the corpus striatum. The 
result of these relations is that a lesion, which is propagated 
from the frontal to the temporo-sphenoidal lobe, or vice 
versa, will pass almost necessarily by the lobe of the insula, 
and thence, in all probability, it will extend to the extra 



196 DISEASES OF THE BRAIN. 

ventricular nucleus of the corpus striatum, seeing that the 
proper substance of the insula, which separates the nucleus 
from the surface of the brain, is composed only of a very 
thin layer." 

The lobe of the insula, or the island of Reil, is found in 
no other mammal than man and the monkey. In the latter, 
however, it is very slightly developed, and has no trace of 
convolutions. In aberrations of speech this part is very 
often involved in the lesion. 

Now, although there are several cases on record in which 
post-mortem examination would appear to show that lesion 
of the third left frontal convolution is sufficient to produce 
derangement of the faculty of articulate language, the 
weight of evidence is decidedly against limiting the seat of 
the organ to this part. Thus, of five hundred and fifty-six 
cases of aphasia tabulated by Seguin, 1 the third frontal con- 
volution was damaged but in nineteen. While, therefore, 
we must admit that injury or disease of this limited region 
will cause aphasia, it is going too far to assert that the 
lesion must exist in this situation in order that aphasia may 
be produced. Moreover, Seguin gives another table of cases 
which must definitely settle the matter, and which I quote 
in full. It relates to autopsies which were made with spe- 
cial reference to the point in question, and in which the de- 
tails given were sufficient clearly to indicate the location of 
the lesion. 

QUESTION OF THIRD LEFT FRONTAL CONVOLUTION. 



AUTHORITIES. 


For. 


Against. 


Trousseau, 1865 (in Acad, de Med.) 

Peter, Legrand, Beclard, Delpech, Berard, Farge, 
Jackson, Bigelow 


14 

3 

1 


18 

8 


Jackson, Kichardson, Russel 




New York Hospital, 1 830-1 867 . . 


1 


Bellevue Hospital, October, 186V 


1 


Total 


18 


34 







1 Op. cit., p. 97. 



APHASIA. 197 

Other cases might readily be adduced, but the above are 
amply sufficient to decide the question against Broca's doc- 
trine. One case of aphasia occurring without lesion of the 
third frontal convolution would of course invalidate his claim 
that this part is the exclusive seat of the organ of language, 
and no number of cases showing coexistence of aphasia with 
disease or injury of the third left frontal convolution would 
be sufficient to establish the point affirmatively with the re- 
sults of our present experience disproved. Nevertheless, as 
showing further that disease of this part will cause aphasia, 
I subjoin the following case from Dr. "W. Ogle's * very in- 
teresting memoir : 

" Joel B., October 18, 1866. Had rheumatic fever and 
endocarditis twenty-five years ago, but since that has had 
good health. While at work, October 15th, fell down sud- 
denly without losing consciousness, and found that he was 
speechless, and hemiplegic on the right side. 

" On admission he was found to have extensive heart- 
disease, with the pulse characteristics of aortic regurgitation. 
There was complete lax palsy of the right arm and leg, with 
unimpaired sensibility. There was at first some difficulty 
in deglutition and in protruding the tongue, but this latter 
symptom passed away in a few days. There was slight pain 
in the left side of the head. 

" His speech was limited to the two words ' yes ' and 
'no.' These he used correctly. After he had been in the 
hospital some time, he recovered the power of saying some 
few words, chiefly monosyllables. 

" He could write with his left hand, with sufficient dis- 
tinctness, words which he could not pronounce when asked 
to do so. In his writing there was often a tendency to re- 
duplication of letters. For instance, he wrote ' Testata- 
ment' for ' Testament.' But I cannot say whether this 
was more than the result of deficient education. 

1 Aphasia and Agraphia. St. George's Hospital Reports, voL ii., 1867, p. 105. 



198 DISEASES OF THE BRAIN. 

" His mind seemed quite clear. He understood all that 
was said to him; took interest in all that was going on 
about him ; listened to conversation with an animated, 
lively look, laughing at any little joke, and expressing 
himself frequently by suitable pantomime. In Decem- 
ber he was attacked by oedema of the lungs, and died on 
the 20th. 

Post-mortem ; cedematous lungs, extensive aortic and mi- 
tral disease. " Much semigelatinous fluid in subarachnoid 
space. Surface of brain healthy, excepting at one limited spot. 
This was the posterior part of the third frontal convolution 
on the left side. Here was a softened, almost diffluent patch 
about three-quarters of an inch in breadth, reaching from 
the highest point of the third convolution backward and 
downward to the fissure of Sylvius. The softened patch 
was not actually the most posterior part of the convolution, 
for there was a narrow unsoftened strip between it and the 
transverse frontal convolution. In cutting into the brain, a 
second small patch of softening was seen in the centre of the 
left hemisphere, external to and rather above the corpus stri- 
atum, and extending toward the posterior termination of the 
fissure of Sylvius. All the rest of the brain was apparently 
healthy. 

" The left middle cerebral artery was firm in its main 
trunk, but in one of its secondary branches at a bifurcation 
was a hard shotty bit of fibrin e completely obstructing the 
passage, so that when water was injected into the vessel it 
could not pass, though considerable force was used. There 
were also fibrinous blocks in the spleen." 

The theory of M. Marc Dax locates the faculty of speech 
in the left hemisphere. He based this opinion upon the fact 
that aphasia is associated almost, if not invariably, with 
right hemiplegia, when there is any paralysis at all. That 
this is really the case is beyond question. Without, how- 
ever, referring again to the cases cited by M. Dax, I quote 
the following table from Dr. Seguin's paper : 



APHASIA. 



199 



APHASIA WITH HEMIPLEGIA. 



AUTHORITIES. 

Trousseau, 1865 (Acad, de Med.) 

Baillarger, later in 1865 (Salpetriere) 

Jackson, loc. cit 

Robertson, loc. cit 

Medical Times and Gazette, September 9, 1865. 

Archives Gen. de Med., 1866 

Flint, New York Medical Record, vol. i. ...... . 

New York Hospital, 1830-'67 

Total 



Right 
Hemiplegia. 



243 



Left 
Hemiplegia. 



125 


10 


30 


1 


34 


3 


3 




2 




2 




4 




43 


3 



17 



From this table we learn that, of two hundred and sixty 
cases of aphasia associated with paralysis, the left hemisphere 
— as determined by the situation of the hemiplegia — was the 
seat of the lesion in two hundred and forty-three cases, and 
the right in only seventeen. 

I also quote the following table from Dr. Seguin : 

QUESTION OF LEFT ANTERIOR LOBE. 



AUTOPSIES BY 


For. 


Against. 


Marc Dax, in 1861, and G. Dax (Acad, de Med., 

1863) 

Bouillaud, 1848 


370 

85 

31 

18 

5 

2 

3 




" 1865 




Trousseau (Acad, de Med.) 

Vulpian (Lecons de Phys.) 

New York Hospital, 1830-'67 

Jackson, Richardson, A. Clark, 1866, 1867 

Peter, Legrand, Beclard, Delpech, Berard, one 
each 


16 
6 

5 


Farge, Bigelow, Detmold, and Stokes, one each. . 


4 


Total 


514 


31 







This table is based on autopsies, and may be considered 
conclusive as to the relative frequency with which aphasia 
is connected with disease of the left anterior lobe. 

From various sources I have obtained the following ad- 
ditional cases, in which the seat of the lesion was determined 



200 



DISEASES OF THE BRAIN. 



either by post-mortem examination or by the situation of 
the hemiplegia : 



AUTHORITIES. 


Left 
Hemisphere. 


Eight 
Hemisphere. 


Larrey 


1 

2 

6 

30 

15 

25 

1 




Falret 






Perroud 




Magnan 




Carrier 




W. Ogle 




Bartholow 




Bateraan 

W. Wadham 


1 
1 


Total 


80 


2 



The immense preponderance of disease of the left hemi- 
sphere, and especially of its anterior lobe, as a concomitant 
of aphasia, is therefore placed beyond a doubt. Indeed, so 
far as I am aware, the fact is not questioned. How, now, is 
it to be explained ? 

We cannot claim, even with all the disparity of cases, 
that the organ of language is located in the left anterior 
lobe, or even in the left hemisphere, to the exclusion of 
the other. Broca has attempted to account for the as- 
sumed restriction, on the ground that the left hemisphere 
receives a larger supply of blood, and is earlier developed 
than the right. This is doubtless correct, but still the fact 
remains that lesion of the right hemisphere is sometimes 
followed by aberrations of speech ; the left remaining per- 
fectly healthy. One such case — and there are several on 
record in which the autopsy confirmed the deductions drawn 
from the symptoms — is sufficient to overturn the theory 
which restricts the situation to one side of the brain ; and 
one such as that reported by Dr. Simpson, 1 in which there 
was extensive lesion of the third left frontal convolution 
in its posterior part, and no epilepsy, paralysis, or aberra- 

1 Medical Times and Gazette, December 21, 1867. 



APHASIA. 201 

tion of speech, is of course utterly destructive of Broca's 
views. 

The fact that aphasia is more frequently conjoined with 
right hemiplegia is undoubtedly due mainly to the fact pre- 
viously insisted upon in my remarks on cerebral embolism, 
that the left middle cerebral artery is much more liable to 
be plugged by an embolus than the right ; and it is by em- 
bolism that aphasia is generally caused. Dr. Hughlings 
Jackson 1 has very satisfactorily worked out the relation, 
and my own experience, presently to be related, abundantly 
confirms the fact. 

At the same time it appears to be clearly shown that the 
left anterior lobe, or rather, in accordance with Dr. Jack- 
son's views, those parts of the brain nourished by the left 
middle cerebral artery, are more intimately connected with 
the faculty of articulate language than any other region of 
the encephalic mass. It is probably true, as originally ad- 
vanced by Dr. Moxon, 2 and since urged by Dr. William 
Ogle, 8 that the organ of speech is to be found in both hemi- 
spheres, and that one side is more generally employed than 
the other, just as we ordinarily give a preference to one eye 
or one ear or one hand, and that this side is the left. Gra- 
tiolet's facts, adopted by Broca to support his view of exclu- 
siveness, will certainly lend force to the argument in favor 
of preference. This careful anatomist found that the left 
hemisphere is developed before the right, and that it is bet- 
ter nourished. Both of these circumstances are owinp; to 
the greater supply of blood which it receives. 

Undoubtedly many of the cases which have been brought 
forward as militating against the doctrine of localization 
of the organ of speech are not cases of aphasia at all, but 
simply instances of inability to speak, from paralysis of the 

1 London Hospital Keports, vol. i., 1. c. 

2 On the Connection between Loss of Speech and Paralysis of the Right Side. 
British and Foreign Medico-Chirurgical Review, April, 1866, p. 481. 

3 Aphasia and Agraphia. St. George's Hospital Reports, vol. ii., p. 83. 



202 DISEASES OF THE BRAIN. 

muscles concerned in speech. This is certainly true of the 
greater number of Seguin's cases, and also, as Bartholow * has 
stated, of those adduced by Ladame. 

Again, in very many instances the post-mortem exami- 
nation has not been properly made, and lesions involving 
one or the other anterior lobe have been overlooked. It is 
now a well-recognized fact that the cerebral tissue may be 
materially diseased, and the lesion not be detected without 
microscopical examination. 

Giving a very full consideration, therefore, to the facts 
and arguments which have been urged on all sides of the 
question, I am constrained, while rejecting the restricted 
location of MM. Dax, and the still more limited situation 
contended for by Broca, to believe : 

1. That the organ of language is situated in both hemi- 
spheres, and in that part which is nourished by the middle 
cerebral artery. 

2. That while the more frequent occurrence of right 
hemiplegia, in connection with aphasia, is in great part the 
result of the anatomical arrangement of the arteries which 
favors embolism on that side, there is strong evidence to 
show that the left side of the brain is more intimately con- 
nected with the faculty of speech than the right. 

These views are further supported by several interesting 
cases, the histories of which I now propose to relate : 

Case I. — In the summer of 1857, while I was on duty, as 
medical officer of the army, with a body of troops and to- 
pographical engineers, making a road from Fort Riley to 
Bridger's Pass, in the Rocky Mountains, a quarrel occurred 
between two of the laborers, which resulted in one of them 
striking the other a violent blow on the head with a club. 
The injured man fell to the ground stunned, and remained 
in a state of coma for several hours. Upon examining him 
a few minutes after the affair took place, I ascertained that 

1 On Aphasia. Journal of Psychological Medicine, etc., vol. il, p. 341, 
et seq. 



APHASIA. 203 

there was no stertor and no indication of paralysis. He 
was unconscious and breathing quietly, with a pulse of 
about 80. He had received a blow on the left temple, 
which, though laying open the scalp, had not fractured the 
skull. Gradually he regained consciousness so as to be able 
to comprehend what was passing about him, but he had en- 
tirely lost the memory of words, though not the faculty of 
articulation. Thus he was unable to speak unless the words 
were first repeated to him, and then he could do so without 
any defect of articulation, provided too many words were 
not given to him at once. 

Thus, when I said to him in Spanish — he was a Mexican, 
and could not speak English — " Como sientes ahora ? " 
"How do you feel now?" he repeated, " Como sien. sien. 
sien.," and then, looking at me in apparent despair, burst 
into tears. And this was repeated time and again during 
the hour I spent with him. 

The next morning, at about seven o'clock, as he attempt- 
ed to rise from his bed, he fell, and was found a few min- 
utes afterward by the hospital attendant, lying on the ground 
in a state of complete coma. I saw him almost immedi- 
ately ; he was breathing stertorously, blowing out his lips 
and cheeks at each expiration, and exhibiting a general res- 
olution of all his limbs. He died at about eleven o'clock 
a. m. that day. 

That afternoon I made a post-mortem examination. On 
removing the calvarium, the first thing that attracted my at- 
tention was an ecchymosed spot about the size of a half-dol- 
lar-piece involving the left anterior lobe at its lateral and 
posterior margin. There was no extensive haemorrhage at 
this point. But, on the opposite side, there had been a rup- 
ture of the middle meningeal artery, and an immense ex- 
travasation of blood which had infiltrated between the lobes 
of the right hemisphere and collected in the base of the skull. 
My theory of the case was that the haemorrhage from the 
artery had been suddenly stopped during the condition of 



204: DISEASES OF THE BRAIN. 

primary insensibility before any considerable quantity of 
blood bad been effused, and tbat during the night his heart 
had recovered its power ; and this, with the muscular effort 
he made in attempting to get out of bed, had dislodged the 
coagulum, and allowed the haemorrhage to take place. At 
that time I attached no especial importance to the injury of 
the left anterior lobe ; but, since the debate in the French 
Academy in 1861, I have had no doubt that to it the amne- 
sic aphasia was entirely due. 

It will be observed that there was no defect of articula- 
tion in this case, either from paralysis or incoordination, but 
that the difficulty was solely as regarded the memory of 
words. 

Case II. — J. H., a captain of a coasting-vessel, consulted 
me in November, 1864, for a difficulty of speech with which 
he had been affected for several months. Upon inquiry, I 
ascertained that one morning early he had been called from 
his bed upon some duty connected with his vessel ; that he 
had risen rather hastily and gone on deck ; that while giv- 
ing an order he suddenly became very dizzy, and fell, uncon- 
scious. He soon regained his senses, but found that he was 
paralyzed on the right side, and had lost the ability to speak. 
He soon afterward reached port, and remained at home for 
three months, during which period the paralysis disappeared 
almost entirely, and he reacquired the ability to speak. The 
aphasia was of both the amnesic and ataxic forms. He could 
neither speak nor write. 

He then went to sea again as a passenger to Cuba, and 
while in Havana had another attack similar to the first, but 
without paralysis of motion, though there was loss of sensi- 
bility on the right side. The memory for words was en- 
tirely destroyed, though he could pronounce distinctly any 
word he was told to say, if he did not allow too long a 
period to elapse between the direction and the response. 
About four months after his last seizure he consulted me. 

At this time he could say a few words, and he employed 



APHASIA. 205 

them to express all his ideas, assisting himself with very en- 
ergetic gestures, which, however, were rarely expressive of 
his thoughts. The words he thus constantly used were " sifi," 
which signified both yes and no, and " time of day," which 
he employed when he had any other answer than simple 
affirmative or negative to give. Besides these expressions, 
he had an oath, " Hell to pay ! " which he ejaculated when- 
ever he did not succeed in making himself understood, and 
sometimes without any such exciting cause. These were 
the only expressions he could originate, but he could pro- 
nounce distinctly any word he was told to say, and even as 
many as three short successive words. When told to write, 
he took the pen, and, on my telling him to give me his name 
and address, wrote " Time of day," and then, seeing that that 
was not the correct answer, immediately followed it with 
" Hell to pay ! " On my remarking to him that he had given 
me wrong information, he immediately wrote " sifi." Any 
word, however, which I told him to write, he did without any 
difficulty, and thus I obtained several long sentences from him. 

From his brother, who came with him, I obtained the 
facts in his history I have mentioned. Examining his heart, 
I found that he had a strong systolic murmur, and was told 
by his brother that he had had, fifteen years ago, a first at- 
tack of acute articular rheumatism, which had been followed 
by several other attacks. 

The main point of interest about this case — and it is 
one of those I shall again draw attention to — is, the occur- 
rence of ataxic aphasia with hemiplegia as concomitants of 
the first attack, while the second was characterized by pure- 
ly amnesic aphasia and no paralysis. 

Case III. — During the winter of 1868-'69, a man came 
to my clinique, at the Bellevue Hospital Medical College, 
who was aphasic, and from whose friends, his own gestures, 
and the few words he could speak, I obtained the following 
history : Some months previously he had been working in a 
stone-quarry, and was struck by some piece of machinery on 



206 DISEASES OF THE BRAIN. 

the left side of the head, at about the junction of the frontal 
with the temporal bone. For a short time he was uncon- 
scious, recovering, however, without paralysis, but with loss of 
the memory of words. When he came under my observation, 
he was very intelligent, comprehended every word said to 
him, and made repeated and persistent efforts to talk, but 
he could not utter a word spontaneously beyond "yes" and 
" no," which he always used correctly. Thus, when I asked 
him where he was born, he became much excited, gesticu- 
lated violently, and apparently made every effort to tell me. 
The perspiration stood out in large drops on his forehead, 
but no sound came from his lips. Then the following con- 
versation took place : 

" Were you born in Prussia ? " " JSTo." 

"In Bavaria?" "No." 

"In Austria?" "JSTo." 

" In Switzerland ? " " Yes, yes, yes, Switzerland, Swit- 
zerland," at the same time laughing, and moving his hands 
actively in all directions. He could pronounce words well, 
but could not write. 

I took occasion to speak at length on the subject of apha- 
sia, and gave it as my opinion that there had been a fracture 
of the internal table of the skull, and that a fragment of 
bone was pressing on the posterior and lateral part of the 
anterior lobe. My friend Prof. Sayre was present, and I 
advised him to trephine the patient, with the view of elevat- 
ing any depressed piece of bone, and restoring the normal 
function of that part of the brain. The operation was per- 
formed a few days afterward, the patient being placed un- 
der the influence of ether. The internal table was found to 
be fractured, and a splinter was pressing on the posterior 
frontal convolution. It was removed, and, as soon as the 
patient emerged from the anaesthetic condition, he spoke 
perfectly well. 

This, as will be seen, was also a case of amnesic aphasia 
unaccompanied by paralysis. 



APHASIA. 207 

Case TV. — A. E., formerly a bookseller, consulted me in 
the autumn of 1869 for what was considered by his friends 
to be, and what probably was, softening of the brain. Be- 
fore any symptom of disease appeared, he had been noted 
for his remarkable memory, but was now exceedingly for- 
getful, especially as regarded words. Thus he had forgotten 
his first name, and could not tell me the names of his chil- 
dren. His conversation was marked by great hesitancy, 
from his not remembering the words he wished to use, and 
there was, besides, marked difficulty of articulation, and 
some words he could not pronounce at all. There was right 
hemiplegia, which had gradually been getting worse, and 
which, when I saw him, was extensive enough to interfere 
materially with the movements of his arm and leg. The 
left side was not affected, and the tongue and face were ap- 
parently not paralyzed. He was subsequently lost at sea in 
the steamer City of Boston. 

This case, therefore, exhibited both the amnesic and 
ataxic forms of aphasia, and was accompanied by right 
hemiplegia. I regard the condition as being due to throm- 
bosis, probably of the left middle cerebral artery. 

Case Y. — "W*. W., aged forty-one, entered the New York 
State Hospital for Diseases of the Nervous System, August 
22, 18T0, hemiplegic on the right side, and affected with 
ataxic aphasia. In the month of March, 1868, as ascertained 
by Dr. Cross, the resident-physician of the hospital, he was 
seized with a dull pain in the right knee, accompanied with 
numbness, formication, and pricking sensations, limited to 
the right foot, while general numbness of the whole side soon 
supervened. These, with loss of power, gradually extended 
and increased till at the end of two weeks the patient was 
entirely hemiplegic. There was at no time any loss of con- 
sciousness nor any mental aberration. On the 11th of May 
following, the patient suddenly lost the power of speech, but 
his mind remained perfectly clear, and, though he could not 
utter a word, he understood well every thing that was 



208 DISEASES OF THE BRAIN. 

said to him. He remained nearly completely aphasic for 
four months, being only able during that time to utter a few 
sounds, which could not be interpreted into intelligible words. 

About September, 1868, he began to enunciate a few 
words, at first very slowly and indistinctly, and gradually 
acquired more facility. When I presented him before the 
class at the Bellevue Hospital Medical College, in Novem- 
ber, 1870, although he could talk, his power of coordination 
was very imperfect, and many words were articulated with 
great difficulty. This trouble was chiefly manifested in re- 
gard to labials and Unguals, such words as " truly rural," 
" Peter Piper," " baker," and others of the kind, causing him 
to make repeated efforts before he could even imperfectly 
pronounce them. There was no paralysis of the tongue, no 
deviation when it was protruded, and but very slight if any 
paresis of the orbicularis oris or other facial muscles. The 
arm and leg on the right side were profoundly paralyzed. 

In this case there was no loss of the memory for words, 
and no difficulty in writing. It was, so far as the aphasia 
was concerned, entirely ataxic in character, and accompa- 
nied by right hemiplegia. 

My opinion was, that the symptoms were to be attributed 
to thrombosis of the left middle cerebral artery. 

Case YI. — E. M., aged twenty-five, noticed one day that 
his right foot was unusually cold. A few days afterward 
he had his first attack of hemiplegia of the right side. Sud- 
denly, and without the least warning, except a severe ver- 
tigo, he fell, but immediately arose. There was no loss of 
consciousness, and with assistance he was able to walk to 
his residence, a short distance off. His face was drawn to 
the left side, and speech and memory were slightly impaired. 

In February, 1869, having recovered motility, he was 
seized with another attack of right hemiplegia. This time 
he partially lost consciousness, and his speech again became 
affected. By April, 1869, he was able to resume his work 
as a weaver, but his arm was still weak. 



APHASIA. 209 

In July he had another attack, which was slight. 

In May, 1870, he again suddenly became hemiplegic on 
the right side. There was no loss of consciousness. The 
face and tongue were affected. With assistance he walked 
home, and in a week had quite recovered. 

In July, 1870, he had his fifth and thus far last attack. 
While chopping wood he was suddenly seized with a violent 
pain in the head, followed by vertigo. He fell, but did not 
lose consciousness. There were right hemiplegia again, dif- 
ficulty of speech, and dilatation of the left pupil. For five 
days afterward he was delirious, but finally recovered, with 
loss of power in the right arm and leg, and increased diffi- 
culty of speech. September 1st, he was admitted to the 
ISTew York State Hospital for Diseases of the Nervous Sys- 
tem. At this time the paralysis had entirely disappeared ; 
the tongue could be moved freely in any direction, and his 
articulation was perfect. But his memory for words was 
greatly impaired, though facts and circumstances were re- 
membered perfectly well. His speech was therefore hesi- 
tating, and if asked to repeat a sentence of three or four 
words he could not do it. Thus he could not repeat the 
words " sugar, coffee, crackers," although he began immedi- 
ately after I had finished saying them. 

Examination showed that the patient had hypertrophy 
of the heart, with aortic insufficiency. 1 My diagnosis was, 
repeated attacks of embolism of the left middle cerebral 
artery, or its branches. 

This case was one of partial amnesic aphasia, with ataxic 
aphasia, which had disappeared with the hemiplegia. 

Case YII. — Mrs. S. H. W., aged thirty- two, married. 
On the 26th of June, 1860, about three weeks after the 
birth of her child, she was suddenly seized with a severe pain 
in the right shoulder, which extended down the arm. Symp- 

1 1 have condensed the histories of this and the preceding case from the re- 
ports of Dr. Cross, in my clinical lecture on Partial Cerebral Anaemia, published 
in the Journal op Psychological Medicine for January, 1871. 
14 



210 DISEASES OF THE BRAIN. 

toms of albuminuria, accompanied by general dropsy, im- 
mediately ensued, and in a few weeks the dyspnoea from 
hydrothorax was alarming. Coma and a convulsion fol- 
lowed. Soon after the fit, which marked the height of her 
disease, as she was sitting by the bed, resting her head on 
her folded arms, her right side became completely paralyzed, 
and she lost the ability to speak. She was not entirely 
clear in her mind for a week after the attack, but gradually 
the dropsy disappeared, her intellect improved, and the pa- 
ralysis became less. 

At the time of the seizure, the face was drawn to the 
right side, the tongue deviated in the same direction, and 
there were strabismus and partial ptosis and paralysis of the 
orbicularis palpebrarum muscle on the right side. Motility 
and sensibility in the right arm and leg were, at first, com- 
pletely abolished, but at the end of ten days she was able to 
move about, by holding on to a chair. During three years 
she continued to improve as regarded the paralysis, but for 
all that period did not speak a word. In the summer of 
1863 she became able to say the word u no," and a few 
months later she could say " yes." 

At my request, she allowed me to present her before the 
class of the Bellevue Hospital Medical College, in Novem- 
ber, 1870, on the occasion of a clinical lecture on aphasia. 

She was then, and is now, enjoying good health, with 
the exception of frequent headache. Her countenance is 
remarkably bright and cheerful, and her whole expression 
is exceedingly intelligent. She comprehends every word 
that is said to her, and attends to all her household duties. 
Yet she is unable to utter any words but " no," " yes," and 
" dado." The latter is seldom employed, but in her vocabu- 
lary signifies affirmation. She uses " yes " for affirmation, 
" no " for negation, and both for doubtful or indifferent con- 
ditions. Thus, if asked how she is, she answers " Yes, yes, 
no, no," which means that she is tolerably well. Sometimes 
she employs these words quite indiscriminately. If asked 



APHASIA. 211 

what that is, pointing to a fan, she cannot tell, nor can 
she repeat the word fan. She shows, however, that she 
knows, by making the gesture of fanning herself. She can 
neither read nor write, although on one occasion she suc- 
ceeded, after great difficulty, in writing "no." Not long 
since, she suddenly ejaculated, " I don't know ! " and a few 
days ago exclaimed, " How do you do ? " but she was not 
able to repeat either of these phrases, nor did she appear to 
be aware that she had said them. Her gestures are very in- 
telligent and expressive. The right arm and leg are weaker 
than on the left side, and the sensibility is less. 

There is a murmur at the apex of the heart with the first 
sound. 

Ophthalmoscopic examination showed the vessels of the 
retina of the left eye to be much larger than those of the 
right. 

In this case I diagnosticated embolism of the left middle 
cerebral artery. 

The aphasia was of both the amnesic and ataxic forms, 
and was accompanied by right hemiplegia. 

Case YIII. — Mr. B. consulted me in November, 1870, 
for loss of the memory of words, and fulness and pain in 
the head, with occasional vertigo. Over a year previously, 
while in the woods of Minnesota buying timber, he had sud- 
denly lost consciousness for a few moments, and on recover- 
ing found that he had become hemiplegic on the right side, 
and had lost the power of speech. For a short time he 
could not utter a word, but gradually the memory of lan- 
guage, and the ability to coordinate the muscles of speech, 
returned to him, and he could articulate sufficiently well to 
be understood. For several months, however, his recollec- 
tion of words was bad. 

For some time he had been under the care of Dr. Hale, 
of Chicago, a homoeopathic physician, who advised him to 
place himself under my charge. When I first saw him, he 
could talk quite well, but there was still a hesitancy in his 



212 DISEASES OF THE BRAIN. 

speech, and occasionally words were misplaced or miscalled. 
Articulation was distinct, and the hemiplegia had disap- 
peared. There was pain, almost entirely confined to the 
left temporal region. There was the history of acute ar- 
ticular rheumatism, and there was aortic insufficiency. 

In this case there had been at first amnesic and ataxic 
aphasia, with right hemiplegia. As the latter disappeared, 
the ability to coordinate the muscles of speech was increased, 
until at last articulation became perfect, and only amnesic 
aphasia remained. 

Case IX. — H. I., a merchant, consulted me in August, 
1869, for hemiplegia, with inability to speak. While sitting 
at his desk, six weeks previously, he suddenly became ver- 
tiginous, and lost consciousness for a few moments. On re- 
covering his senses, he discovered that he was paralyzed on 
the right side, and that he could not speak a word. He was 
exceedingly anxious to make known some wish, and one of 
his clerks brought him paper and a pencil, but he could not 
write a letter. An alphabet was then written, but he was 
unable to select the letters to form the words he wanted to 
use. 

A physician was sent for, and Mr. I. was bled to the ex- 
tent of sixteen ounces, without any favorable result. He 
remained hemiplegic and completely aphasic for about two 
weeks. He then began to walk, and acquired the ability to 
say " what," " certainly," and " saw my leg off," which he con- 
tracted into " sawmelegoff," accentuating strongly the ulti- 
mate syllable. These words he used without apparent in- 
telligence, though he clearly understood all that was said to 
him, and laughed at any joke as heartily as ever. His con- 
dition was about the same when I saw him. 

He could protrude his tongue, and move it actively in 
all directions, but could not articulate any words but those 
mentioned. Thus, when I asked him to say "table," he 
said, " Certainly ; " and when I said, " Well, say it then," he 
exclaimed, " Sawmelegoff! " at the same time, to show that 



APHASIA. 



213 



he understood what I said, he went across the room, and 
put his hand on a table, uttering, at the same time, his full 
stock of words, " what," " certainly," " sawmelegoff." 

I then asked him if he could write ; he replied, " Cer- 
tainly." I placed paper before him, and gave him a pen 
with ink, but he was unable to write his name as I re- 
quested, although he could use his fingers for other things 
tolerably well. I asked him to draw a series of parallel 
lines, and he did so without difficulty. On my insisting that 
he should now make an effort to write his name, he made 
the attempt with this result : 



Fig. 7. 



I told him that was not his name, at which he gesticulated 
violently, exclaimed, " Sawmelegoff! " and gave me one of 
his visiting-cards. This gentleman continued under my care 
for some time, but with no perceptible change. He had 
had two attacks of acute articular rheumatism, and had, 
when I saw him, both aortic and mitral insufficiency. 

Here, then, was right hemiplegia, with fully-developed 
ataxic and amnesic aphasia. My diagnosis was, embolism 
of the left middle cerebral artery. 

Case X. — Miss C. R., of strongly-marked hysterical 
diathesis, suddenly became aphasic while sitting at the 
breakfast-table. I saw her about two hours subsequently, 
when she drove to my office with her mother. There was 
no paralysis, the tongue could be moved freely in all direc- 
tions, articulation was perfect, and she could pronounce 
any word mentioned before her. The memory of words 
was, however, entirely abolished. 

Case XI. — Mr. S., a retired merchant, consulted me in 
September, 1870, for the effects of cerebral haemorrhage. 
He was hemiplegic on the right side, and unable to talk. 



214: DISEASES OF THE BRAIN. 

His intelligence was good. He could read, but he was not 
able voluntarily to pronounce a word. The tongue was not 
in the least paralyzed, nor had it been. Occasionally ejacu- 
lations of various kinds would come forth. On one occa- 
sion, as he entered my office, he exclaimed — he was a Ger- 
man gentleman — " Guten Morgen, mein Herr," but by no 
effort could he repeat that or any other expression. His 
attempts to speak were continuous while he was with me ; 
and his son who came with him said he was almost always 
trying to talk while he was not sleeping. 

This case was, therefore, one of ataxic aphasia, and 
was marked by the existence of right hemiplegia. Cere- 
bral haemorrhage, involving the corpus striatum, was the 
cause. 

Case XII. — Mr. L. 1ST., a German gentleman, came under 
my care in September, 1869, for symptoms indicative of cere- 
bral softening. He was slightly paralyzed on the right side. 
His speech was affected both amnesically and ataxically. 
Soon afterward, in consequence of maniacal symptoms mak- 
ing their appearance, I sent him, with the concurrence of my 
friend Prof. Flint, to the Lunatic Asylum, at Flushing. He 
remained there till September of the present year, gradually 
failing in mental and physical power, when, as he was no 
longer in a condition to injure himself or others, his friends, 
with my approval, removed him to their own home. At 
the present time he can scarcely remember a word, and his 
articulation is very defective. A remarkable feature of his 
conversation is that he calls every thing " kazze," " cat." 
He appears to have forgotten every other word. 

The history of this case points to thrombosis as the prob- 
able lesion. 

Case XIII. — This was a very remarkable and instructive 
case, one which I have already mentioned under the head of 
embolism. 

The patient was a retired officer of the army, and con- 
sulted me in the autumn of 1869 for paralysis, vertigo, and 



APHASIA. 215 

slight difficulty of speaking, from which he had suffered for 
some months. Several years previously he had been un- 
der the care of my friend Dr. Metcalfe for acute rheumatism, 
with cardiac complications. The Hstory of the case pointed 
strongly to embolism, and, as the paralysis involved the 
right side, I diagnosticated a previous attack of embolism of 
the left middle cerebral artery. 

The difficulty of speech was slight ; there were both am- 
nesic and ataxic aphasia. 

Under the treatment employed he improved very much 
in the ability to walk, to use his arm, and to speak, so much 
so that he and his friends considered him better than he had 
been for several years. But about six weeks after he came 
under my charge he had another attack. This time the left 
side was paralyzed, and there was no difficulty of speech. 
Galvanism was employed, as before, and he recovered suffi- 
ciently to go to Washington City. While there he had a 
third attack, characterized by right hemiplegia and aphasia. 
He soon recovered his power of speech, and soon afterward 
had a further attack, involving the left side, and unattended 
by aphasia. He recovered under the care of Dr. Basil Norris, 
of the army, and soon afterward came again to New York. 
A short time after his arrival I requested my friend Prof. Flint 
to see him in consultation, with the special view of having 
him examine his heart. This was done with thoroughness, but 
no abnormal sounds were detected. While in New York he 
had two other attacks, during both of which he was deliri- 
ous; both were characterized by hemiplegia. That of the 
left side was unaccompanied by aberrations of language ; 
that of the right was attended with ataxic and amnesic apha- 
sia. He forgot the names of the most ordinary things, and 
there were many words that he could not articulate at all. 
Thus, when he wanted a fan, he called it " a large, flat thing to 
make a wind with." He forgot my name, and could not pro- 
nounce the words beetle, general, physician, and many others. 
I sent him to Newport greatly improved, but he had other 



216 DISEASES OP THE BRAIN. 

attacks there, and finally died in the antumn of the present 
year, of, I presume, cerebral softening. 

The interesting features of this case are the concurrence 
of hemiplegia and ataxic and amnesic aphasia, and the strik- 
ing fact that there was no aphasia when the paralysis in- 
volved the left side. Thus, according to my views of the 
case, the patient had repeated attacks of cerebral embolism. 
"When the embolus lodged in the left middle cerebral artery, 
there was aphasia accompanied by right hemiplegia ; when 
the embolus obstructed the right middle cerebral artery, 
there was left hemiplegia, but no aphasia. 

Case XIV. — In the early part of December, 1870, J. M., 
a patient of Bellevue Hospital, was, at his request, brought 
to my clinique at the college. His history, as given me by 
Dr. Judson, showed that he had repeated attacks of uncon- 
sciousness or semi-unconsciousness, which were accompanied 
with hemiplegia. Dr. Flint had also detected a bellows 
murmur, but it was at the apex of the heart. The patient 
had suffered from several seizures of acute articular rheuma- 
tism. 

Upon inquiry, I ascertained that he had had altogether 
eleven attacks of vertigo, unconsciousness, and hemiplegia. 
His intelligence was good, and he spoke tolerably well, 
though with hesitation and occasional difficulty of articula- 
tion. His speech was much better than it had been, and 
there was no well-marked hemiplegia. 

As in the case last mentioned, whenever the hemiplegia 
had been on the left side there was no aphasia, but when it 
was on the right side there was always well-marked difficulty 
of speech, both amnesic and ataxic. 

The only other case, similar to these last two, that I have 
been able to find, is one reported by Dr. Stewart, 1 of a man 
who was admitted into the Middlesex Hospital, suffering 
from left hemiplegia, without aphasia. A week later he be- 
came affected with right hemiplegia and loss of speech. He 

1 Medical Times and Gazette, July 9, 1864. 



APHASIA. 217 

died, and on post-mortem examination both middle cerebral 
arteries were found plugged with emboli. 

The views which the cases I have observed have led me 
to form, have been confirmed by my recent study of the sub- 
ject of aphasia. These have already been given in part, 
but the detail of the foregoing; histories enables me to ex- 
press the remainder with more confidence. 

It cannot have failed to strike the reader that, in all the 
cases of which hemiplegia formed a feature, the aphasia was 
of the ataxic form, while when there was no hemiplegia the 
aphasia was amnesic. In the one the individual was de- 
prived of speech because he could not coordinate the muscles 
used in articulation, in the other because he had lost the 
memory of words. 

This is a point which has not hitherto been noted. The 
phenomena indicate, I think, very clearly the seat of the 
lesion, and the physiology of the parts involved. 

The gray matter of the lobes presides over the idea of 
language, and hence over the memory of words. When it 
only is involved, there is no hemiplegia, and there is no diffi- 
culty of articulation. The trouble is altogether as regards 
the memory of words. 

The corpus striatum contains the fibres which come from 
the anterior column of the spinal cord, and is besides con- 
nected with the hemisphere. A lesion, therefore, of this 
ganglion, or other part of the motor tract, causes paralysis 
of motion on the opposite side of the body. The cases I 
have detailed show, without exception, that the power of 
coordinating the muscles of speech is directly associated 
with this hemiplegia. A lesion, therefore, followed by hemi- 
plegia and ataxic aphasia, indicates the motor tract as the 
seat. If amnesic aphasia is also present, the hemisphere is 
likewise involved. An analysis of the cases reported by 
Ogle, Jackson, and some other observers, shows that the 
association existed in their cases, although they have not 
noticed it as of any physiological or pathological bearing. 



218 DISEASES OF THE BRAIN. 

Another important feature of the foregoing cases is the 
constant association of the aphasia with right hemiplegia 
where there was any paralysis at all. This indicates, per- 
haps, only the more frequent occurrence of embolism on the 
left side, but the last two cases, as well as the one quoted 
from Dr. Stewart, show that the left hemisphere is more in- 
timately connected with the faculty of speech than the right. 
In fact, it appears to me impossible to avoid this conclusion. 

So much for some of the various theories which exist 
relative to the localization of the organ of language and 
for the clinical history of aphasia. I have not thought it 
necessary to discuss the view of Schroeder van der Kolk, 1 
that the faculty of articulate speech resides in the corpora 
olivaria, because there is little if any physiological or patho- 
logical evidence to sustain it. Nor the hypothesis of Brown- 
Sequard, 2 that speech is a reflex phenomenon, because there 
is no evidence in support of that opinion. Neither have I, 
though much tempted, ventured into the philosophy of the 
subject to any considerable extent. 

As to the causes, the prognosis, diagnosis, morbid anat- 
omy, and pathology, they have been sufficiently considered 
in the remarks made, and the treatment is of course that of 
the pathological condition to which it is due, whether this 
be cerebral haemorrhage, embolism, thrombosis, softening, 
hysteria, wounds, the bites of poisonous serpents, or other 
cause. One point, however, should be mentioned in this 
connection, and that is, that constant efforts should be made 
to exercise the vocal organs, by attempts to speak, and by 
the application of the galvanic or faradaic currents to the 
tongue and other muscles concerned in articulation. 

1 On the Minute Structure and Functions of the Spinal Cord and Medulla 
Oblongata. New Sydenham Society Publications, p. 140. 
8 Seguin's Memoir, already quoted 



CHAPTEK VIII. 

ACUTE CEREBRAL MENINGITIS. 

By acute cerebral meningitis is understood inflammation 
of two membranes of the brain — the pia mater and arach- 
noid. Some writers have made the attempt to discriminate 
between inflammation of the arachnoid and inflammation 
of the pia mater, but there are no diagnostic marks by 
which such a distinction can be made, and we find from 
post-mortem examination that neither membrane can be 
inflamed without the other participating in the morbid pro- 
cess. Inflammation of the dura mater is never included un- 
der the term meningitis. 

The ancients made no distinction between the several 
inflammatory affections of the intra-cranial organs, but com- 
prehended them all in one disease which they called frenzy 
— (pprfv, the brain. Morgagni, however, showed that the 
membranes of the brain were the parts generally involved, 
and gave a very accurate account of the phenomena of an 
attack of acute meningitis. Since then, Rostan, Lallemand, 
Andral, Bouillaud, and others, have added to our knowl- 
edge. 

Symptoms. — The symptoms of acute cerebral meningitis 
may be divided into three groups, arranged in chronological 
order : the stage of invasion, the stage of excitation, and 
the stage of collapse. 

1. The Stage of Invasion. — The most prominent initia- 
tory symptom is headache, which may be diffused or con- 
fined to a limited part of the head. "When this latter is the 



220 DISEASES OF THE BRAIN. 

case, the frontal region is more generally its seat ; next in 
order of frequency is the occipital, and next the temporal. 
At the same time, the face is flushed, the eyes are red and 
suffused, and there is a decided elevation in the temperature 
of the head, which is not only felt by the patient, but may 
be perceived by the hand of the physician. Vomiting is 
generally present. 

As might be expected, these symptoms are accompanied 
by fever. This, however, rarely runs high, so far as the force 
or the frequency of the pulse is concerned, or as regards 
the heat of the skin. It is mainly characterized by restless- 
ness and insomnia. Occasionally there is a tendency to 
somnolence. 

This stage may last a few days or only a few hours, or 
may be so slight as not to attract attention. In general fea- 
tures it resembles the prodromatic stage of cerebral conges- 
tion. 

2. Stage or Period oe Excitement. — A chill ushers in 
this stage, and an increase in the intensity of several of the 
symptoms of the first stage, and the development of others, 
soon take place. Thus the fever becomes higher, the skin 
hotter, and the temperature of the body is elevated sev- 
eral degrees. The pulse is frequent, quick, and hard, and 
the face becomes redder than in the first stage. The pain 
in the head augments in violence, and is increased by press- 
ure on the scalp, or even the slightest movement. 

The eyes are bright, the pupils contracted and painfully 
sensitive to light. The hearing becomes morbidly acute, 
loud noises cause great agony, and even slight sounds are 
unbearable. The general sensibility of the body is increased, 
and hence the patient is rendered uncomfortable by the con- 
tact of the bedclothes with the skin. Delirium is generally 
present from the first, and is often of furious character. 
Hallucinations of sight and hearing are almost constant, and 
the irrationality of the ideas is marked by the incoherence 
of the speech. The patient when awake is continually talk- 



ACUTE CEREBRAL MENINGITIS. 221 

ing, gesticulates violently, and weeps and laughs alternately 
over imaginary evils. It is sometimes necessary to use re- 
straint to prevent him injuring himself or others, and the at- 
tendants should always be prepared for any emergency of 
the kind. As the disease advances, the delirium becomes 
more subdued, and the patient may exhibit some evidences 
of sanity. 

Even when there is no delirium, as occasionally happens, 
the influence of the morbid action over the mind is shown 
in the irritability of the patient, and the change which he 
undergoes in character and disposition. 

Convulsions rarely occur in adults, but motility generally 
is nevertheless disordered. The limbs are in almost continual 
action, as are likewise the jaw and the eyelids. Twitchings 
of the facial and other muscles, such as those of the forearm, 
are usually well marked, and occasionally there are irregu- 
lar movements of the eyeballs. Convulsions, when they oc- 
cur, may be either clonic, or tonic, or both. Thus there 
may be a gradually-increasing rigidity of some muscles, fol- 
lowed by relaxation and disordered movements. Sometimes 
there is opisthotonos as well marked as in some cases of 
tetanus. Hemiplegia or paraplegia may occur, but are in- 
frequent complications. I have seen two cases in which, one 
lateral half of the body was paralyzed during the whole 
course of the disease. 

Contractions of the limbs sometimes take place, and may 
be confined to one side or a single limb. In this case the 
forearm is usually strongly flexed on the arm. 

The muscles of organic life participate, and the bowels 
are obstinately constipated. There may be difficulty of swal- 
lowing, from spasm of the pharynx, and irregularity of breath- 
ing, from implication of the respiratory muscles. 

The most characteristic symptom of this stage is, how- 
ever, the obstinate and violent cephalalgia, of which mention 
has already been made, and yet there are cases in which it 
is entirely absent from first to last. Several such instances 



222 DISEASES OF THE BRAIN. 

have been under my own charge, and post-mortem examina- 
tion has verified the existence of the evidences of meningitis. 
This stage lasts from a few days to two weeks. 

3. Stage or Period of Collapse. — The beginning of 
this stage is marked by the occurrence of somnolence, 
which often shows a tendency to pass into coma, and by a 
subsidence of the delirium and muscular agitation. There 
are times, however, during which the stupor remits in pro- 
fundity, and the patient appears to be somewhat conscious 
of his condition, but these periods only occur in the first part 
of the third stage. Ere long the coma becomes constant. 

Paralysis then supervenes and is first manifested in the 
ocular or facial muscles. Thus from paralysis of one of the 
muscles of the eyeball strabismus ensues, or the upper eyelid 
may drop from paralysis of the levator palpebral superioris. 
The pupils dilate and become insensible to light, and the 
mouth is drawn to one side from implication of the muscles 
of the face. Before long the contractions of the limbs relax, 
and paralysis takes place. The sphincters of the bladder 
and rectum also lose their power, and the urine and fasces 
escape involuntarily. The pulse becomes slow and irregular, 
but the temperature, as Jaccoud has shown, and as I have 
lately verified in several instances, does not fall. The insen- 
sibility becomes more and more profound, and the patient 
dies in a state of coma, sometimes from asphyxia produced 
by paralysis of the respiratory muscles, but generally from 
the gradual engorgement of the lungs. 

Such is the ordinary course of an attack of simple acute 
meningitis occurring in a young and healthy person. But 
there are modifications often met with which require consid- 
eration. Of these, epidemic cerebrospinal meningitis is 
scarcely to be considered a disease of the nervous system, 
and tubercular meningitis will be discussed under a sepa- 
rate head, but the differences due to acute rheumatism and 
old age may very properly be noticed in the present connec- 
tion. 



ACUTE CEREBRAL MENINGITIS. 223 

CEREBRAL RHEUMATISM. 

By this term is signified the inflammatory condition in- 
duced in the membranes of the brain by an attack of acute 
articular rheumatism. The relation has been recognized 
from the very earliest period, but, though alluded to by Flint 
and other American writers, does not seem to have attracted 
marked attention in this country. My own experience, how- 
ever, satisfies me that meningitis of a distinct form is often 
caused by rheumatism. 

The membranes of the brain may become affected during 
the second week of an attack of acute rheumatism. The 
swollen and painful joints become less swollen and less pain- 
ful, and the patient may be convulsed, or, what is more com- 
mon, exhibits choreiform movements in the limbs. 

The delirium, which is generally present, is similar to 
that met with in alcoholism. There are the same trembling 
of the limbs and tremulousness of the lips. 

A marked point of difference between rheumatic and 
simple meningitis consists in the entire absence in the first- 
named of cephalalgia and vomiting, but it is frequently 
characterized by the presence of severe pain in the back, 
which may extend as high as the occiput. This was a promi- 
nent feature in more than half the cases that have been un- 
der my observation. The subsequent cause of rheumatic 
meningitis does not differ from that of the simple form of 
the disease. Coma and collapse ensue, with a general re- 
mission of the violence of the symptoms. Death, however, 
generally ensues, and in the way already described. 

SENILE MENINGITIS. 

In old persons the symptoms of acute meningitis are 
rarely so pronounced as in individuals of middle age. The 
affection comes on more gradually, and may have made con- 
siderable progress before its existence is suspected. There 
is little or no pain, no fever, and no gastric or intestinal de- 
rangement. The mental symptoms are very similar to those 



224 DISEASES OF THE BRAIN. 

due to softening. The patient has imperfect articulation, 
his memory is impaired, and he does things which show 
that he is not in his right mind. The delirium is of the low 
muttering kind, and there is a tendency to coma even in 
the first stage. There is a more or less general paresis in 
all the limbs, and subsultus is commonly present. Death 
is usually due to pulmonary engorgement. 

Causes. — Among the predisposing causes of acute cere- 
bral meningitis, age is first to be considered. Guersant 1 
asserts that the period of life between sixteen and forty-five 
is that during which acute meningitis is most liable to oc- 
cur, not including children, who are far more prone to the 
disease than adults. Rilliet and Barthez 2 have, however, 
shown that very young infants are not so subject to simple 
acute meningitis as children of from jive to eleven years 
of age. The very opposite opinion is expressed by Drs. 
Meigs and Pepper. 3 

Nine cases of acute simple meningitis have come under 
my observation. Of these, all were between the ages of 
thirty and forty. 

Men are more subject to it than women. Of my cases, 
seven were males and two females. Parent-Duchatelet and 
Martinet, 4 however, think women are more predisposed to 
the affection than men. 

Temperature, either very high or very low, predisposes 
to acute meningitis. Five of the cases under my care oc- 
curred in summer and four in winter. 

Certain professions and habitudes appear to favor the 
occurrence of the disease. Among the former are all those 
which require the head to be exposed to strong and direct 
heat ; among the latter are excessive intellectual exertion, 

1 Art. Meningite, in Dictionnaire de Medecine, Paris, 1839. 

2 Traite des Maladies des Enfants, Paris, 1853. 

3 A Practical Treatise on the Diseases of Children, Philadelphia, 1870, p. 
464. 

4 Recherches sur l'lnflammation de l'Arachnoide, Paris, 1821. 



ACUTE CEREBRAL MENINGITIS. 225 

and abuse of alcoholic liquors. Tertiary syphilis, gout, and 
rheumatism, are likewise predisponents. 

Of exciting causes, injuries of the head from falls or 
blows of different kinds stand first. Next is exposure to the 
direct rays of the sun, or other source of great heat, and 
then recession of an exanthematous affection, such as scar- 
latina, measles, or erysipelas, and the irritation of dentition, 
or intestinal worms. 

Diagnosis. — Acute meningitis may be confounded with 
partial or circumscribed encephalitis, but the distinction is 
made by considering that in the latter the headache is less 
severe, the delirium less marked, and the convulsions and 
contractions weaker. Moreover, the febrile excitement is 
much greater in acute meningitis than in partial encephali- 
tis, and the whole disease more pronounced. 

The meningitis of the aged bears a considerable degree 
of resemblance to cerebral softening ; but the fact that the 
first-named affection is more rapid in its progress, and is not 
preceded by symptoms due to other morbid conditions, will 
generally enable the practitioner to make a correct diag- 
nosis. 

From delirium tremens it may be distinguished by the 
history of the case, by the greater tendency to insomnia ex- 
hibited in alcoholism, and by the general character of the 
delirium. The febrile excitement of acute meningitis, the 
pain in the head, the heat of the skin, the absence of clammy 
perspiration, and the increased temperature, as shown by 
the thermometer, are conclusive diagnostic marks. 

From typhoid fever meningitis is diagnosticated by the 
existence in the former of meteorism, abdominal tenderness, 
and petechia?, by the facts that the headache and febrile ex- 
citement are less, and that diarrhoea is present and vomiting 
is not. 

Prognosis. — This is always grave. Occasionally death 
takes place in a few hours, and generally before the tenth 
day. When the disease is prolonged beyond this latter pe- 
15 



226 DISEASES OF THE BRAIN 

riod, the prognosis becomes more favorable. The occur- 
rence of strabismus or other paralytic affection lessens the 
hope of a favorable termination. Prof. Flint, however, has 
cited two cases occurring in the hospital practice of himself 
and Dr. Thomas, in which there were strabismus, hemiple- 
gia, and coma, both of which recovered. He also cites 
another case in which there was strabismus, and in which 
recovery took place. Hiccough is an unfavorable event. 

Of the nine cases observed by myself seven died. In all 
of these fatal cases there was strabismus. In the two cases 
which recovered there was no squinting. The deaths in the 
fatal cases all occurred before the tenth day, and two took 
place before the end of the third day. 

Morbid Anatomy. — If death occurs during the second stage 
of the disease, the most marked appearance found in the 
membranes is redness from increased hyperemia. If, how- 
ever, it is delayed till the third stage, effusion of serum is 
the prominent feature. In a case of which I made a post- 
mortem examination last summer, and which was caused by 
the great heat of the season, there was an extensive collec- 
tion of bloody serum in the cavity of the arachnoid, and the 
pi a mater was so adherent as to bring with it a layer of the 
gray matter of the brain as it was stripped off. 

The fluid may consist solely of pus, or this may be 
mingled with serum in all proportions. The pus, with the 
fibrine of the exuded serum, forms thin plates of membrani- 
form texture, which are scattered over the surface of the in- 
flamed region or may entirely cover it. 

If death has taken place late in the course of the disease, 
evidences of the implication of the cerebral substance will 
generally be discerned. These consist in the gray substance 
becoming of a pinkish color, and the white, when cut, show- 
ing numerous puncta vasculosa. The ventricles rarely con- 
tain any considerable amount of fluid, and are often entirely 
empty. The latter was the case in the instance above men- 
tioned. 



ACUTE CEREBRAL MENINGITIS. 227 

Pathology. — The symptoms of the first and second stages 
are due to congestion ; those of the third mainly to effusion 
and consequent pressure. 

An important question connected with the pathology re- 
lates to the determination, from the symptoms, what part of 
the brain is the seat of the lesion. The upper convex por- 
tion of the hemispheres is intimately related to the purely 
intellectual functions of the brain, while the under surface, 
or base, is connected with the motility of various parts of 
the body. Thus, if the inflammation be strictly limited to 
the upper surface of the brain, the predominant symptoms 
are those involving intellectuality, and consequently there 
is delirium, marked by incoherence of ideas and irrational- 
ity of language. If, on the contrary, the base of the brain 
alone is affected, the chief manifestations of disease are seen 
in the muscular system, and there are contractions, spasms, 
convulsions, and paralysis. When the morbid action ex- 
tends to both regions, there is a combination of these phe- 
nomena. 

But, as Jaccoud 1 states, there are some stubborn facts 
which stand in the way of the unreserved acceptance of the 
law laid down, for it occasionally happens that the symp- 
toms are not in direct relation with the seat of the lesion. 
Thus in the case, the post-mortem examination of which I 
have referred to, there had been spasms and paralysis, yet 
the convex surface of the right hemisphere was alone in- 
volved, and that to an extent not exceeding a third the size 
of the hand. Jaccoud explains such cases by attributing to 
the cerebral symptoms a double origin ; one set being due 
directly to the part affected, the other resulting from sec- 
ondary reflex excitation. The explanation seems logical. 

Another fact should also be taken into consideration. 

In acute cerebral meningitis there is very frequently a large 

effusion of serum or an extensive formation of pus. If 

either be collected on the upper convex surface of either 

1 Op. cit., p. 212. 



228 DISEASES OF THE BRAIN. 

hemisphere, the pressure exerted through the intervening 
brain-substance upon the motor tract at the base must pro- 
duce more or less derangement of motility on the opposite 
side of the body. 

Guyot, 1 who has given very careful study to the localiza- 
tion of the lesion from a consideration of the symptoms, de- 
clares that it is possible to define the seat very accurately, 
but his manner of looking at the subject places it in alto- 
gether a different position from that which Jaccoud gives 
it. Thus, tracing the fibres of the motor tract through the 
white substance to the convex surface of the hemispheres, 
he associates lesion of this region, not only with disturbances 
of ideation, but with derangement of motor functions. In 
this view he is supported by the experience of MM. Parent- 
Duchatelet and Martinet, 2 who state that in eight subjects 
who had exhibited hemiplegia in the beginning of paralysis 
on one side of the body, they had discovered, on post-mortem 
examination, effusion on the convexity of the opposite hemi- 
sphere. 

When, however, the lesion is limited to the base, the 
functions of the hemispheres will not be affected, except 
upon the principle of reflex irritation or of the transmission 
of pressure. It is evident, however, that further researches, 
based upon post-mortem examinations, are necessary to the 
satisfactory solution of the interesting questions involved. 

Treatment. — To afford any chance of a favorable result, 
the treatment should be energetic from the first. 

General bloodletting may be practised with advantage 
in subjects of good constitution and of the middle period of 
life. As much as twelve or sixteen ounces may be taken 
from the arm if the pulse is hard, the cephalalgia intense, or 
the delirium furious. Leeches applied behind the ears or to 
the inside of the nostrils are more generally of advantage. 
The same may be said of cups to the nucha. 

1 Du Rapport des Symptoms avec les Lesions dans la Meningite. These de 
Paris, 1859. 2 o p . cit. 



ACUTE CEREBRAL MENINGITIS. 229 

The hair should be cut off short, and ice kept constantly 
applied to the scalp during the first and second stages. It 
is better than the cold douche, for the reason that it is al- 
most impossible to continue the latter without intermissions, 
during which the head again becomes hot. Compresses 
wrung out of cold water will not answer ; they soon get heat- 
ed, and act as poultices. Irrigation, by a small stream of 
ice-water falling from a vessel placed above the head of the 
patient, is a useful means of applying cold, but is often in- 
convenient. 

Purgatives are generally advantageous and should be ef- 
fective. ^Nothing is better than croton oil, although calomel 
and podophyllin, grs. x with grs. ij, make a good combina- 
tion for the purpose. 

My experience has satisfied me of the good effects of mer- 
curialization. I have administered calomel in doses of a 
grain every two hours until the breath became fetid, and 
I am sure the effect has been beneficial. 

The iodide of potassium is well spoken of by Dr. Flint, 1 
who says he has witnessed the good effects of the drug in 
several cases. Dr. F. B. Lyman a has reported two cases in 
which it formed a prominent feature of the treatment, and 
in which recovery took place. 

Within late years in the few cases of acute cerebral men- 
ingitis that have been under my charge, I have found the 
greatest benefit from the bromide of potassium, and the 
three cases that recovered were instances in which it was ad- 
ministered in large doses. The theory upon which its em- 
ployment is based has already been fully considered in the 
chapter on cerebral congestion. It should be administered 
in doses of at least thirty grains three or four times a day, 
from the very beginning of the affection to the end of the 
second stage or the appearance of coma, should this symp- 
tom supervene. 

The head should be kept well elevated, the chamber cool, 

1 Op. cit., p. 601. 2 American Medical Times, 1862, p. 334. 



230 DISEASES OF THE BRAIN. 

and well ventilated, the light in a great measure excluded, 
and the utmost quiet enjoined. 

The food, without being stimulating, should be nutri- 
tious. Nothing is superior to strong beef-tea, made either 
from fresh beef or from some one of the extracts in the mar- 
ket. 

In the third stage the treatment should be almost the 
reverse of that indicated as proper for the first and second 
stages. The mercury, iodide of potassium, bromide of potas- 
sium, ice to the head, and purgatives should be omitted, and 
attention should be given to the maintenance of the strength. 
To this end brandy, whiskey, or other alcoholic liquor, should 
be administered in such quantities as the occasion seems to 
require. It often happens in this stage that the delirium 
and excessive motility return. It must be remembered 
that this is not from any renewal of morbid processes with- 
in the cranium, but is entirely due to debility. At the mo- 
ment of writing this, a young lady of this city is under my 
charge for acute cerebral meningitis, whom I did not see till 
the third stage was well advanced, and who for several days 
previously had exhibited a return of the delirium, for which 
depletive measures and hydrate of chloral had been employed. 
The free administration of brandy, champagne, and beef-tea 
soon dissipated the symptoms of relapse, and she bids fair to 
recover. 

Blisters may be used in this stage with advantage. They 
are best applied between the shoulders, and should be six or 
eight inches square. 

In the rheumatic form of the disease little special treat- 
ment is necessary. It is, perhaps, advisable to endeavor, by 
means of blisters or other revulsives, to bring back the dis- 
ease to the joints. 

In the acute meningitis of the aged, active depletive treat- 
ment is not so generally admissible, and if apparently indi- 
cated should be carried out cautiously. It may even be 
proper to treat some cases with stimulants from the very first. 



CHAPTER IX. 

CHRONIC CEREBRAL MENINGITIS. 

Although sometimes a consequence of an acute attack, 
chronic cerebral meningitis is more generally an original 
affection. 

Symptoms. — The symptoms of chronic cerebral meningi- 
tis are very similar to those indicative of softening. These 
are headache, somnolency, trembling, defective articulation, 
feebleness of the limbs, paralysis of the bladder, or of the 
sphincters of the bladder and rectum, producing involuntary 
discharges of urine and faeces, weakness of the memory, and 
general enfeeblement of all the mental faculties. The prog- 
ress of the disease is slow, and therefore these symptoms may 
extend over several months or even years. They may, how- 
ever, at any time be intensified by the development of a more 
acute form of inflammation. 

Chronic cerebral meningitis, when due, as it may be, to 
syphilitic infection, runs its course more rapidly, and the 
symptoms are more decided. The third nerve is particu- 
larly liable to be involved, and hence there are ptosis, stra- 
bismus, double vision, and alterations in the normal size and 
motility of the pupils. The facial may likewise be involved, 
causing paralysis or spasms, and the fifth, giving rise to neu- 
ralgia, anaesthesia, or destruction of the eyeball from de- 
ranged nutrition. 

Under the name of "general paralysis" Calmeil 4 de- 
scribed an affection which is not uncommon among the in- 

1 De la Paralysie Consideree ehez les Alienes, Paris, 1826. 



232 DISEASES OF THE BRAIN. 

sane, and which may be developed in persons not the sub- 
jects of mental alienation. A prominent morbid condition 
in snch cases is frequently chronic meningitis, but the pecu- 
liarities of general paralysis are sufficiently well marked to 
require for it a separate consideration. 

Causes. — The etiology of chronic cerebral meningitis fre- 
quently cannot be ascertained. It is sometimes the result of 
an acute attack, and, when it arises spontaneously, may be 
due to the excessive use of alcoholic liquors, or to syphilitic 
infection. Beyond this our knowledge does not extend. 

Diagnosis. — This is often impossible to be made out, with 
even a moderate degree of exactness, and is always difficult. 
The affection may be confounded with cerebral softening, 
and the most careful study will in many cases fail in mak- 
ing the discrimination between them. The difficulty is fre- 
quently heightened by the fact that the two diseases co- 
exist. 

Prognosis. — This is almost invariably unfavorable, unless 
a syphilitic origin can be discovered, in which latter case the 
prospect of recovery is very materially enhanced. 

Morbid Anatomy and Pathology. — The essential feature in 
the morbid anatomy of chronic cerebral meningitis is a new 
formation of connective tissue, by which the membranes 
adhere to each other and to the brain, and by which they 
are rendered opaque and thicker than normal. 

In addition there may be deposits of exudation on the 
convexity or base of the brain, which, though intimately 
connected with the alterations of the membranes, are yet 
distinct from them. 

The seat of the lesion may probably be determined with 
more exactness than in the acute form of the disease, for the 
reasons that the morbid process is extended over a longer 
period, and that the symptoms accordingly are more discrete, 
and that they are not marked by delirium and fever. The 
same principles are applicable to the inquiry, as have already 
been laid down. 



CHRONIC CEREBRAL MENINGITIS. 233 

Treatment. — The very active treatment adopted by some 
practitioners never leads to favorable results, and only seems 
to annoy or exhaust the patient. The syphilitic variety of 
the affection may generally be successfully combated by 
the iodide of potassium and mercury ; but the simple, un- 
complicated form is quite unamenable to therapeutic meas- 
ures. For the former there is no better combination than 
that of bichloride of mercury, with iodide of potassium in 
solution, so that the one-sixteenth of a grain of the bichlo- 
ride is taken, with from ten to thirty of the iodide, three 
times a day. Even if the disease have not a syphilitic ori- 
gin, this is probably the best treatment which can at pres- 
ent be suggested. In either form antiphlogistic measures 
are contraindicated. On the contrary, wine and highly-nu- 
tritious food are frequently productive of amelioration. 



CHAPTER X. 

TUBERCULAR CEREBRAL MENINGITIS. 

Inflammation of the membranes of the brain, attended 
with or due to a deposit of miliary tubercles, was for many 
years considered as a disease peculiar to infancy, and was 
known as acute hydrocephalus before its morbid anatomy 
and pathology were clearly comprehended. It is now well 
understood to be an affection to which adults are liable. 

By some authors, especially Robin and Bouchut, it is 
regarded as not being tubercular in character. It has hence 
occasionally been termed granular meningitis. Although 
mentioned by the ancient medical writers, no clear and 
systematic description of tubercular meningitis was given 
till "Whyte 1 published his essay on the subject of dropsy of 
the brain. Since that time it has received the attention of 
many writers in this country, Great Britain, France, and 
Germany. 

Symptoms. — Whyte defined three periods of the disease, 
which he marked by the state of the pulse. I think the 
symptoms may be properly arranged in four stages : 1. The 
prodromatic stage; 2. The stage of excitement; 3. The 
stage of depression ; and 4. The stage of recurrence. 

1. The Pkodromatic Stage. — This period may be alto- 
gether wanting, or may be so slightly manifested as not to 
be noticed. Generally, however, it is well marked. 

1 Observations on the most Frequent Form of the Hydrocephalus Interims, 
viz., Dropsy of the Ventricles of the Brain. Works of Robert Whyte, edited 
by his son. Edinburgh, 1768, p. 725. 



TUBERCULAR CEREBRAL MENINGITIS. 235 

If the child be sufficiently advanced in years, a change 
of disposition is among the first symptoms perceived. Thus 
the temper becomes irritable, caresses are disregarded, and 
dislike is shown for those amusements which formerly gave 
pleasure. At the same time the appetite disappears, and 
the child loses flesh rapidly. This iatter is not noticed about 
the face, but is mainly confined to the abdomen and limbs. 
The bowels are generally obstinately constipated, but occa- 
sionally there is diarrhoea. Headache is not often com- 
plained of ; neither is vomiting a common symptom of this 
period. Fever is not continuous, although it is generally 
present at irregular times of the day. 

The prodromatic stage may last only a few days, or may 
be prolonged for two or three months. 

2. The Stage of Excitement. — This period is ushered 
in by obstinate vomiting, which is present in many cases, 
even though no food be taken. Intense pain in the head is 
a coincident symptom, and is so severe that the child puts 
his hands to his head and cries out or awakes screaming. 
Convulsions may also occur. They do not differ in general 
appearance from the ordinary epileptic paroxysms, and may 
be repeated several times. 

Yery early in this stage the fever becomes more persist- 
ent than in the first stage, although it may still be irregular. 
The pulse, however, is not hard and resisting, as in other 
inflammatory affections, but is soft and compressible. 

Trousseau 1 has called attention to a condition of the 
skin present in tubercular meningitis, which he at first re- 
garded as peculiar to this disease, but which subsequent in- 
vestigation showed was likewise found in simple meningitis, 
in typhoid fever, and some other affections. If the finger- 
nail be passed lightly over the surface of the abdomen or 
the thorax so as to trace a series of lines, in about thirty 
seconds the skin becomes red — the color being at first dif- 
fused, but very soon the lines made by the nail are indicated 

1 Op. cit., Le9on lv., Fievre Cerebrale. 



236 DISEASES OF THE BRAIN. 

by a still redder color, which persists a long time. Trous- 
seau calls this appearance the " cerebral stain " (tache cere- 
hrale). The phenomenon he attributes to a profound modi- 
fication in the vascularization of the skin ; and although it 
is not to be regarded as absolutely pathognomonic, it is a 
sign of very great importance. 

The intellectual faculties are not yet affected to any 
considerable extent, but the changes of character and dispo- 
sition, and indifference to things which formerly excited in- 
terest, are still well marked. 

The physical strength, though lessened, is still not yet so 
far reduced as to oblige the patient to remain in bed. 

The tongue is usually coated and red at the edges, the 
appetite diminished, and the bowels are obstinately consti- 
pated. 

The temperature of the body is elevated, but not to an 
extreme degree ; the thermometer indicating from 101° to 
103° F. Sometimes there are distinct remissions in the vio- 
lence of all the symptoms, but the disease nevertheless goes 
on to its full development. The transmission from the 
second to the third stage is often marked by an ameliora- 
tion which may last several days. 

From what has been said, it will be seen that the charac- 
teristic phonomena of this stage are headache and vomiting. 
Its duration varies from seven to fourteen days. 

3. Stage of Depression. — The pulse, which in the 
previous stage was sometimes as high as 140, and some- 
times as low as 80, now becomes less rapid than is nor- 
mal, and may even fall below 50. At the same time the 
beat is quick, but the interval between the pulsations is at 
times so great that the observer is, as Dance 1 says, fearful 
that the action of the heart has stopped. The interval be- 
tween the pulsations is often irregular, and this may be 
regarded as a sign of unfavorable import. 

In young infants there is a reduction in the temperature 

1 Memoire sur l'hydrocephale. Archives Gen. de Med., 1830. 



TUBERCULAR CEREBRAL MENINGITIS. 237 

of the body below the normal standard, which lasts through- 
out the whole of this period. Roger regarded this reduc- 
tion, preceded as it is by a higher temperature, and followed 
during the succeeding stage by another elevation, as pathog- 
nomonic of tubercular meningitis. 

The continued excitement of the previous stage is re- 
placed in this by a strong tendency to somnolence, which 
alternates with a rather quiet delirium. The patient lies on 
his back, with the eyes fixed, but yet not looking at any 
object with attention. Events transpiring around him no 
longer attract notice, and, though when addressed in a loud 
tone he may turn his gaze toward the speaker, it is very 
evident that the words convey no idea to his mind. 

The fingers are kept in almost continual motion, picking 
up threads and other small objects from the bedclothes, and 
occasionally clutching at imaginary things. Again, the fin- 
gers are alternately opened and shut without any real or 
apparent motive, and again the head is turned restlessly 
from side to side of the pillow. Convulsions are very gen- 
erally present from time to time during this stage, and may 
be so frequently repeated as to leave scarcely any interval 
between the seizures. Even if the attacks do not involve 
the body generally, the eyes scarcely ever escape ; there be- 
ing strabismus, convulsive movements of the pupils, and 
constant motions of the eyeballs. The facial muscles are 
likewise often affected. 

In the intervals of wakefulness, the cephalalgia contin- 
ues, and causes the peculiar scream which is so character- 
istic as to have received the name of the " hydrocephalic 
cry." It is a sound such as might be produced by mingled 
emotions of terror and grief. Although probably excited 
by the pain, it is more or less automatic, and is not exactly 
such a cry as would be produced by unmixed, physical suffer- 
ing. It is accompanied, however, by that contraction of the 
muscles of the face indicative of suffering. 

The paleness of the countenance continues, but at times 



238 DISEASES OF THE BRAIN. 

there is a sudden redness, which disappears as rapidly as it 
comes. 

The conjunct! vae are generally injected, and photophobia 
is present. M. Bouchnt, 1 who has given great attention to 
the subject of ophthalmoscopy in diseases of the nervous sys- 
tem, finds peripapillary congestion, dilatation of the retinal 
vessels, and deformation of the papillae. 

There is often a general hyperesthesia of the skin, for 
which, however, anaesthesia may be substituted. When this 
latter is the case the conjunctivae participate, and inflamma- 
tion results. 

The limbs are weak, and, should the patient attempt to 
walk, the gait is staggering. The speech is . hesitating, is 
rarely indulged in except in response to questions, and then 
with the least possible expenditure of words. 

The vomiting, which formed so prominent a symptom of 
the previous stage, has ceased, but the constipation still per- 
sists. 

The respiration is irregular, sometimes being rapid and 
sometimes slow. Occasionally there are deep sighs, followed 
by numerous quick inspirations, and again the respiratory 
movements may be so slight as scarcely to be perceived. 
This variation from the normal action, as well as the irregu- 
larity of the heart's movements, is due to the implication of 
the pneumogastric nerves at their origins. 

This stage may last for from two or three days to two 
weeks. 

4. Stage of Recurrence. — The characteristic pheno- 
mena of this stage are the return of the fever and the 
increase in the violence of the symptoms indicative of 
cerebral disturbance. Before its onset there may be a pe- 
riod of nearly complete intermission, so that the impression 
may be formed that recovery is taking place. This apparent 
cessation of the morbid action, however, only serves, with 

1 Du Diagnostic des Maladies du Systeme Nerveux par l'Ophthalmoscopie, 
Paris, 1866, p. 45, et seq. Plates iv., v., vi., vii., viii., ix., and xi., of the Atlas. 



TUBERCULAR CEREBRAL MENINGITIS. 239 

the experienced observer, to make the reappearance of the 
symptoms more striking. 

Convulsions are more frequent and violent than in the 
previous stage, and tonic contractions of the limbs are not 
uncommon. These contractions are more generally met 
witli in the muscles of the neck and upper extremities, and 
vary from time to time in their intensity. The head is thus 
thrown backward, and, as the morbid action frequently ex- 
tends to the muscles of the back, an appearance in the pa- 
tient not unlike that present in tetanus is produced. 

Paralysis eventually supervenes. At first this is incom- 
plete, affecting only a single limb or the muscles of the face, 
but it extends, and both limbs on one side or an arm and a 
leg of opposite sides become involved. Yoluntary power is 
lost, but reflex movements can be excited by pinching or 
tickling. 

The delirium acquires increased intensity, and alternates 
with the somnolence, which likewise becomes more profound, 
and which gradually masks all the other symptoms, till at 
last the coma is persistent and general, and spinal sensibility 
is lost. 

Before death the pulse rises in frequency, a cold sweat 
makes its appearance, and the patient dies either by a slow 
process of asphyxia, or in convulsions. 

The fact that tubercular meningitis is not confined to in- 
fants is now generally admitted. Dance * was the first to 
recognize its occurrence in adults, and Gerhard, 2 of Philadel- 
phia, a few years subsequently reported several cases. Le- 
dibuder 3 also pointed out the analogy between the tubercu- 
lar meningitis of infants and that of adults, and still later 
Yalleix 4 gave the weight of his authority to the same 
effect. 

1 Op. cit. 2 American Journal of the Medical Sciences, 1834. 

3 Essai sur l'Affection Tuberculeuse Aigue de la pie-mere, Paris, 1837. 

4 De la Meningite Tuberculeuse chez l'adult. Archives Generate de Mede- 
cine, 1838. 



24:0 DISEASES OF THE BRAIN. 

So far as the symptoms are concerned, I have never 
been able to perceive any essential points of difference 
between the tubercular meningitis of children and that of 
adults. 

The affection is, of course, modified, as are all other dis- 
eases, by the age of the patient, but, when allowance is made 
for this factor, the morbid process is one and the same in 
character. In adults, however, it generally supervenes in 
the course of tuberculosis of the lungs, whereas in infants it 
is ordinarily a primary manifestation of the tubercular diath- 
esis. 

Causes. — Tubercular meningitis is an expression of a gen- 
eral state of the system. To enter at length into the ques- 
tion of its etiology would necessarily involve a discussion of 
the cause of the diathesis to which it is essentially due. 
Nevertheless, there are a number of determining causes that 
may be appropriately considered. Age is an important fac- 
tor in determining the accession of tubercular meningitis. 
It is rare during the first year of infancy, but is more com- 
mon during the period extending from the second to the 
seventh year than any other time of life. From eight to ten 
it is much less frequent, and from ten to fifteen is rarely 
seen. 

In adults it is most common between the ages of seven- 
teen and thirty. From thirty to forty it is rare, and after 
forty is scarcely ever met with. 

Males are more frequently the subjects of tubercular 
meningitis than females, and this holds good for all ages 
of life. 

The season of the year appears to exercise no influence. 

As to many other exciting causes alleged by authors, 
such as blows, emotional excitement, and previous diseases, 
nothing very definite is known. The same cannot, however, 
be said of the morbific influence of bad air, insufficient food, 
improper clothing, neglect of cleanliness, and a disregard for 
other sanitary requirements. 



TUBERCULAR CEREBRAL MENINGITIS. 241 

Diagnosis. — Tubercular meningitis is liable to be con- 
founded with several other affections, and can sometimes 
only be distinguished with difficulty. 

From simple meningitis it may be diagnosticated by the 
facts that the onset of the former is sudden, while the latter 
is insidious in its approach, and slow in the development of 
its symptoms ; the one goes on steadily through its course, 
the other halts and remits; in the one the temperature of 
the body rises several degrees, in the other the elevation is 
scarcely ever more than two degrees ; in the one there is no 
hereditary tendency, while in the other inquiry will usually 
reveal the existence of hereditary tubercular predisposition. 

The mental symptoms show a marked difference. In 
simple meningitis the delirium is often furious, and is always 
very active ; in the tubercular form of the disease the de- 
lirium is quiet, and alternates with stupor. 

In typhoid fever there may be vomiting and headache, 
but the bowels are not constipated, and there is tenderness 
over the right hypogastric region. Moreover, the epistaxis, 
the eruption, and the swelling of the spleen, which occur 
in typhoid fever, will aid in making the diagnosis more cer- 
tain. 

"Worms in the alimentary canal may give rise to a set of 
symptoms very similar to those which form the prodromata 
of tubercular meningitis. As Jaccoud observes, therefore, 
it is well, whenever a child exhibits these symptoms, to ad- 
minister one or two doses of a strong vermifuge. 

A peculiar affection, to which young infants are liable, 
may be mistaken for tubercular meningitis. It was first 
described by Dr. Gooch, 1 but derived its name — " hydroceph- 
aloid disease" — from Dr. Marshall Hall. I have already 
alluded to this disorder under the head of cerebral anaemia. 
In it the child is irritable, restless, starting at every noise, 
moving in sleep, and often waking screaming. Yomiting is 

1 On Some Symptoms in Children erroneously attributed to Congestion of the 
Brain. Gooch's Essays, New Sydenham Society, 1859, p. 179. 
16 



24:2 DISEA.SES OF THE BRAIN. 

frequently present, but the bowels are loose. The whole 
appearance of the child betokens exhaustion, and, if due 
care be not taken, death may ensue. The absence of con- 
stipation, the history of the case, and the depressed state of 
the fontanelle, if this be yet open, will suffice to render the 
diagnosis clear. 

Trousseau considers the irregularity of the respiration 
the most important sign indicating the presence of tuber- 
cular meningitis. "In no other disease," he says, "will 
you meet with this singular anomaly. You will not 
observe this unequal and irregular respiration either in 
the essential convulsions of infancy or in typhoid fever. 
I have reason, then, for insisting on the importance of the 
symptom." 

Prognosis. — There is not much to say under this head. 
The ordinary termination of the disease is death. I have 
never seen a case recover; and, though instances with a 
favorable result have been reported, I am disposed to think 
the diagnosis of such has been erroneous. Drs. Meigs and 
Pepper, 1 of thirty-one cases, had no recovery, though they 
report a case of tuberculosis of the meninges — not tuber- 
cular meningitis — in which recovery appears to have taken 
place, though the child died a year or two afterward with 
dysentery. 

It seems contrary to reason to expect a radical cure in a 
disease in which the cause cannot be removed. Do what 
we will, the tubercular deposit remains ; and, as Jaccoud 
remarks, the reported cases of recovery were rather in- 
stances of a long remission in the intensity of the symp- 
toms. 

Morbid Anatomy and Pathology. — A question arises at the 
outset of an inquiry relative to the morbid anatomy of tu- 
bercular meningitis, which refers to the essential character 
of the disease ; and that is, whether the gray semi-trans- 

1 A Practical Treatise on the Diseases of Children. Philadelphia, 1870, p. 
452. 



TUBERCULAR CEREBRAL MENINGITIS. 24:3 

parent granulations met with on post-mortem examination 
are tubercles, or whether they are an entirely distinct 
morbid product ? Yalleix, Rilliet and Barthez, Barrier, 
Grissole, Meigs and Pepper, and others, regard them as tu- 
bercles. Grissoll expresses himself clearly on this point. 
" We have no doubt," he says, " that these granulations are 
tubercles in a rudimentary state ; for we have many times, 
in the same subject, followed the morbid product in its dif- 
ferent phases of evolution from the amorphous condition to 
the fully-developed tubercle." 

On the other hand, Bouchut, basing his conclusions 
mainly on the microscopical observations of Robin, is of 
the opinion that the granulations are formed : 1. Of fibro- 
plastic elements, consisting of free nuclei and fusiform cells, 
and ovoid cells. The nuclei are ovoid or spherical, and gen- 
erally very small, not exceeding 0.008 to 0.009 in. in diam- 
eter. 2. Of a great quantity of granular amorphous homo- 
geneous matter, which keeps the other elements strongly 
united. 3. Of a few vessels and fibres of connective tissue. 
Among all these elements the tubercular corpuscles of mi- 
crographers are not to be found ; and, therefore, the disease 
cannot be regarded as tubercular in character. M. Empis 1 
also contends that the microscopical analysis shows that the 
gray granulations are entirely distinct from tubercle. On 
the other hand, it is alleged — and I am disposed to think with 
force — that the most which the investigations of M. Robin 
and others in accord with him show, is, that there is no 
special characteristic of tubercle which will enable us to 
declare with certainty that it is present, and that it does 
not possess a structure which is the same in all stages of its 
development. The collateral evidence goes very far to sup- 
port the view that the granulations are tubercular in char- 
acter. 

The question which also arises, as to whether the inflam- 
mation precedes the tubercular deposit, or vice versa, is gen- 

1 Traite de la Granulie. Paris, 1865. 



244 DISEASES OF THE BRAIN. 

erally decided in favor of the prior appearance of the tuber- 
cles. The granulations are met with in the course of the 
vessels of the pia mater. This membrane is always more 
or less iaflamed, and is thickened by the infiltration of 
sanguinous, serous, plastic, or purulent exudations. The 
granular or tubercular matter is likewise deposited at the 
base of the brain, and in this position is doubtless the cause 
of the derangements of motility which constitute so promi- 
nent a feature of the disease. 

The tissue of the brain is not generally much involved, 
although on section the red points, indicative of the situa- 
tion of blood-vessels, are very much increased in number. 
Occasionally there are small extravasations of blood found 
in the gray substance. 

The ventricles are distended by serum, and this is some- 
times so great in quantity as to cause the rupture of the 
septum lucidum. The liquid is either clear and limpid, 
milky from the presence of pus-globules, or bloody from 
containing red corpuscles. 

The morbid anatomy of the lungs and other organs, al- 
though interesting in the present connection, need not be 
dwelt upon ; suffice it to say that tubercular deposits are 
always met with in some one or more of the viscera and 
especially in the lungs. 

Treatment. — In regard to a disease so uniformly fatal as 
tubercular meningitis, there is not much to say. The prin- 
cipal advice I have to give is, to refrain from blisters, anti- 
monial ointment, leeches, and drastic purgatives, which 
have no other effect than to shorten the life of the patient, 
and to make his existence still more intolerable than it is 
made by disease. Iodide of potassium does less harm, but 
I have never known it do any good. Memeyer, however, 
recommends it, and many will doubtless continue to employ 
it on his authority. 

When we have any reason to suspect an hereditary ten- 
dency to tubercular meningitis, prophylactic measures may 



TUBERCULAR CEREBRAL MENINGITIS. 245 

be used with hope of success. These consist in providing 
for pure air, ample clothing, nutritious food, and in the ad- 
ministration of cod-liver oil, iron, iodine, and quinine. A 
climate not subject to sudden vicissitudes, and of such a 
character as regards warmth and dryness that the patient 
can spend a great portion of the day in the open air, is also 
a matter of prime importance. 



CHAPTEE XL 

SUPPURATIVE ENCEPHALITIS OB CEBEBBITIS. 

Suppurative inflammation of the brain is a very rare 
affection uncomplicated with meningitis. In this latter 
connection it has already been sufficiently considered. In 
the present chapter, therefore, I shall discuss it solely as an 
independent lesion, and mainly in reference to the subse- 
quent formation of abscess. 

Symptoms. — The symptoms of suppurative inflammation 
of the brain vary according to the seat of the lesion, and are 
rarely of such a character as to enable us to say, with any 
great degree of certainty, that we have a case of uncompli- 
cated encephalitis before us. Nevertheless, certain phe- 
nomena have been recognized, and, after death, the evi- 
dences of inflammation of the brain have been discovered. 
But these symptoms are, many of them, met with in other 
cerebral disorders, and therefore cannot be regarded as pa- 
thognomonic. It is difficult, if not impossible, to arrange 
them in stages ; and therefore, after the prodromata, I shall 
consider the phenomena of acute encephalitis in accordance 
with their relation to the several functions of the organism 
liable to be affected. 

The premonitory symptoms are similar to those of cere- 
bral congestion, and doubtless depend upon a like patho- 
logical condition. Thus there are vertigo, pain in the head, 
noises in the ears, troubles of vision, numbness, and difficul- 
ties of speech. They never, however, last as long as they 
do in simple congestion. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 247 

Sometimes the first-observed symptom of approaching 
encephalitis is an epileptiform convulsion. 

In the fully-established disease the phenomena are very 
decided, but at the same time have no necessary or con- 
stant relation with the pathology, as similar symptoms are 
met with in other very different affections. 

Disorders of Sensibility. — At first, there is generally 
hyperesthesia ; subsequently, anaesthesia. Headache is a 
common symptom, as it is in so many other cerebral diseases. 
There is no particular location of the pain — sometimes the 
frontal region, at others the occipital, and again the vertical 
or parietal regions, being its seat. It varies, likewise, as re- 
gards intensity and form, and may consist of a feeling of 
fulness or constriction only. It is present from the very be- 
ginning of the disease, and usually continues through its 
whole course. 

Pains are felt in various parts of the body, are sharp and 
lancinating, and often attended with cramps. Cutaneous 
hyperesthesia is also occasionally met with. 

In the next place, there is anaesthesia, with all its accom- 
paniments of formication, numbness, and other abnormal 
sensations of the kind, mainly affecting the face and upper 
extremities. As to the special senses, the sight is almost 
always deranged. There are bright flashes of light, irides- 
cent appearances, and photophobia, all showing increased 
irritability of the retina. The pupils are contracted, the 
conjunctivae suffused, and the eyeballs are the seat of a dull, 
aching pain. Subsequently, the pupils become dilated, and 
vision is lost. Ophthalmoscopic examination shows, in the 
early stages, papillary infiltration, with retinal congestion, 
and later, papillary atrophy and granular degeneration, the 
results of optic neuritis. There is also, generally, double 
vision, to which allusion will be more fully made directly. 

The hearing is at first very acute, and even slight noises 
are more or less painful. Noises in the ears, of various 
kinds, are present. As the disease advances, the hearing 



248 DISEASES OF THE BRAIN. 

becomes much, impaired, and is gradually lost, in one or 
both ears. 

The taste and smell are rarely affected. 

Disorders of Motility. — As with the sensibility, the mo- 
tor organs of the body at first exhibit evidences of increased 
excitability. Thus, there are twitchings of the muscles, 
mainly of those of the face, and clonic or tonic spasms. 
Sometimes these last for several days. Subsultus is especi- 
ally noticed in the flexor tendons of the wrist. 

General convulsions may take place, with or without loss 
of consciousness. Frequently the action is limited to one 
side of the body, or implicates one side of the face, or a 
single limb. Strabismus occurs, and double vision is pro- 
duced, at this stage, from spasms of one of the ocular muscles. 

This period of muscular excitation corresponds very ac- 
curately with the stage of augmented sensibility. 

It is succeeded by a period of diminished motor power. 
Paralysis generally begins in a distant part of the body, and 
slowly involves one side. Thus, there may at first be a dif- 
ficulty in raising the toes, or in grasping things with the 
fingers ; then the knee becomes weak, the flexors of the 
thigh follow, and the whole limb drags. If the arm be the 
first member affected, the difficulty advances from the fin-' 
gers to the elbow, and thence to the shoulder. Sometimes 
the morbid action extends equally on both sides of the body, 
and then the gait becomes weak and shuffling. The legs 
are spread wide apart, so as to increase the base, and keep 
the centre of gravity more easily within it. The knees are 
bent, the pelvis is flexed on the thighs, and the whole body 
is inclined forward. The face rarely escapes. It may be 
affected on one side only, in which case there is distortion, 
or there may be a gradual failure of muscular power on 
both sides. The muscles connected with the eyes almost 
always suffer. Ptosis is common, and external strabismus, 
causing double vision, accompanies it, both being produced 
by the implication of the third or motor oculi nerve. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 249 

One side of the face sometimes becomes permanently 
contracted, and thus an appearance is produced somewhat 
resembling that which is caused by paralysis of the opposite 
side. It may be distinguished from this latter condition, 
however, by the fact that in it the eyelids are spasmodically 
closed, and the side of the face much more distorted than 
when there is paralysis of the opposite side. The tongue is 
always, in my experience, prominently affected. The first 
sign of diminished motility is the frequency with which it 
is bitten, in conversation or mastication, and sometimes it 
is made quite sore, on one or both sides, or at the tip, from 
this cause. Then the patient discovers that long-continued 
speaking causes a sensation of fatigue, at the root of the 
tongue, and that a feeling as if this organ were too large for 
the mouth is experienced. Then articulation becomes in- 
distinct, the words are clipped or slurred over, so that at 
times it is difficult for others to understand what he says. 

Disorders of Intelligence. — The first indication of mental 
weakness is the susceptibility experienced to the influence 
of emotions. The patient will thus get uncontrollable fits 
of laughing or crying from very slight causes, and some- 
times from no apparent cause. These paroxysms are fre- 
quently of mixed character, the patient passing from laugh- 
ing to crying, and vice versa. 

The memory begins to fail at a very early period, espe- 
cially as regards the names of things. The enfeeblement is 
by no means, however, confined to words, but facts and cir- 
cumstances likewise fail to be remembered. Gradually a 
condition of complete dementia ensues, and finally coma, 
with or without previous or alternating delirium. 

Disorders of the Functions of Organic Life. — There is 
always febrile excitement in encephalitis. At first the pulse 
is frequent, rising to 120, but as the disease advances it falls 
till toward the close it goes below the normal standard. 
It is characterized, according to Barras, 1 by a characteristic 

1 Bulletin de la Societe Medicale d'Emulation, Juin et October, 1823. 



250 DISEASES OF THE BRAIN. 

tremulousness (tremMottement), which he compares to the 
unequal vibrations of a cord moderately stretched. This 
peculiarity he attributes to irregular arterial dilatation. 
According to my experience, the symptom is by no means 
constantly met with, and it certainly is not pathognomonic, 
for the same peculiarity of pulse is found in several other 
disorders. In a case, however, now under my care, in which 
there is reason to suspect encephalitis and abscess, the phe- 
nomenon is present in a marked degree, not only in the ra 
dial artery but in the temporal and the angular, as it passes 
between the nose and the inner angle of the orbit. 

The respiration in the first stages is not materially de- 
ranged, but later it becomes irregular and stertorous, and 
finally asphyxia may take place. 

The temperature of the body is elevated till the fever 
abates, and paralysis makes its appearance. The thermome- 
ter rarely, however, goes above 103° Fahr., and is generally 
a degree below this point. 

The digestive organs usually show more or less evidence 
of derangement. Constipation is always a prominent fea- 
ture, and the appetite is capricious. At times the patient 
refuses to eat, at others he will cram his stomach with all 
kinds of edibles. Digestion is often troublesome, and occa- 
sionally dangerous from paralysis of the pharyngeal muscles. 
Cases are on record in which death has occurred by the food 
becoming impacted in the throat, and several cases have 
come under my own notice, in which, from a like cause, a 
fatal result was barely prevented by the use of very ener- 
getic measures. 

Moreover, the secretions of the mouth are almost always 
altered either in quantity or quality, or both, and the sensi- 
bility of the tongue and faucial mucous membrane is often 
impaired. Hence, the patient is not aware that he has filled 
his mouth, and goes on cramming it with food, which makes 
an alimentary mass larger than can pass through the oesopha- 
gus. This course, even without the pharyngeal paralysis, in- 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 251 

terferes with the act of swallowing. The faeces are sometimes 
passed involuntarily, but this is almost entirely a feature of 
the last stage. Nausea and vomiting are present more or 
less from the very first. 

There may be either retention of urine from paralysis of 
the bladder, or incontinence from paralysis of the sphincter. 
Or both conditions may coexist, giving rise to a constant 
dribbling. 

These symptoms may be arranged in five classes, desig- 
nated by the most prominent feature of each : the paralytic, 
the comatose, the epileptiform, the apoplectiform, and the 
maniacal. 

Complications may and often do arise. Thus there may 
be meningitis, temporary congestions, extravasation of blood, 
effusion of serum, or some intercurrent visceral affection. 

The tendency of acute encephalitis is to suppuration and 
the consequent formation of abscess, and many of the symp- 
toms enumerated are due to the supervention of this condi- 
tion. Death ensues gradually from exhaustion or asphyxia, 
or may take place suddenly from the bursting of the abscess 
into the ventricles, or upon the surface of the brain. 

Causes. — No age is exempt from the disease, although it 
is more common in old persons than in adults of middle age 
or young persons. 

It is probably more common in males than females solely 
from the fact that they are more subject to the exciting 
causes of the disease. Among these are the inordinate use 
of alcoholic liquors, venereal excesses, extreme intellectual 
exertion, great emotional disturbance, and exposure to ex- 
treme heat. 

It may also be induced by disease of the internal ear, by 
erysipelas affecting the head, or by severe attacks of scarlet- 
fever, small-pox, or other eruptive disease. 

The most common cause, however, is injury of the brain. 

Diagnosis. — The diagnosis of suppurative encephalitis is, 
in the first stages, difficult if not impossible ; the symptoms 



252 DISEASES OF THE BRAIN. 

being common, as I have already said, to several other dis- 
orders. From cerebral haemorrhage the distinction can be 
made without difficulty, for, although encephalitis may be 
developed with rapidity and by an apoplectic seizure, the 
tendency is for the subsequent phenomena to become pro- 
gressively more marked, while in haemorrhage there is a 
gradual amelioration. The pulse in haemorrhage is from the 
first slow and regular, unless the medulla oblongata be the 
seat, while in encephalitis it is rapid and irregular. 

Meningitis is always associated with superficial encepha- 
litis, and hence the symptoms bear a certain amount of re- 
semblance to those of the affection under consideration. 
But the latter is, in general, characterized by the facts that 
the paralysis is more defined, both in intensity and location ; 
that the delirium is less acute ; that the cephalalgia is not 
so intense, nor the delirium so prominent or constant a phe- 
nomenon. 

In epilepsy the paroxysm is the main phenomenon of the 
disease. When this ceases, the patient in general recovers 
his ordinary mental faculties, but the epileptiform seizures 
of suppurative encephalitis are never followed by complete 
intellectual restoration. 

The disease with which it is most likely to be confound- 
ed is that which, from its obvious characteristics, is denomi- 
nated general paralysis. I know of no diagnostic marks 
between the two conditions, except that general paralysis is 
usually of longer duration, and is especially apt to affect the 
insane. 

The symptoms due to tumors are often almost identical 
in character with those attendant on abscess. The history 
of the case is our only safe guide. The fact that the brain 
has received an injury of some kind will indicate suppura- 
tive encephalitis as the probable difficulty. A lady is, at 
the moment of writing this, under my charge, who has been 
successively treated by several of the most skilful diagnos- 
ticians of this city, at times for abscess, and again for tumor, 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 253 

and I venture to say that no one, without the aid of a post- 
mortem examination, can say which lesion exists. 

Prognosis. — Suppurative encephalitis is invariably fatal, 
if the disease does not terminate in resolution. As Jaccoud, 
however, remarks, cases of alleged cure before the stage of 
suppuration is readied must always have an element of un- 
certainty about them, and do not therefore permit us to 
mitigate the unfavorable character of the prognosis. Drs. 
Gull and Sutton, 1 while stating that there is nothing in the 
morbid anatomy of cerebral abscess which makes it neces- 
sarily an incurable affection, admit that practically it is 
irremediable. In this opinion I unhesitatingly concur. 

Morbid Anatomy and Pathology. — Suppurative encephalitis 
is a local disease restricted in its action, and hence affecting 
a limited and well-defined region of the cerebral tissue. 
This may vary from the size of a walnut to that of the 
closed fist, and is ordinarily irregularly spherical in shape. 
Although never of a diffused character, there may be, at the 
same time, several centres of inflammation. The part most 
frequently affected is the gray matter of the cerebrum — the 
morbid process involving the white substance in its progress. 
Next, the cerebellum appears to be a favorite seat. The 
corpora striata, and the optic thalami, are also frequently 
involved. 

It sometimes happens that the pus which results from 
the inflammatory action is not collected in a cavity, but is 
infiltrated into the subjacent tissue. In such cases there is 
no well-defined abscess, but a pulpy mass is found on exam- 
ination after death, consisting of the elements of the brain- 
substance in a more or less disorganized condition, with 
those of the blood intermingled with pus — the whole of a 
greenish-yellow color. 

Again, there may be a collection of pus, but at the same 
time the walls are imperfectly formed, and there is infiltra- 
tion to some extent. Lastly, the puriform deposit is entirely 

1 Abscess of the Brain. Reynolds's System of Medicine, vol. ii., p. 544. 



254: DISEASES OF THE BRAIN. 

limited by a membrane consisting of connective tissue, and 
forming a cyst. The cerebral substance in contact with the 
walls of an abscess gradually breaks down, and hence the 
cavity undergoes constant enlargement in all directions, but 
especially in the lines of least resistance. If the abscess is 
near the surface of the hemisphere, the tendency is to en- 
large toward the external periphery ; if it is situated in the 
central part, in the corpora striata or optic thalami, the ab- 
sorption of the peripheral tissue takes place in the direction 
of the ventricles. In the first instance, when the rupture 
ensues, the pus will be extravasated into the cavity of the 
arachnoid ; in the second, it will be poured out into the 
ventricular cavities. In either case, coma and death will 
result if the amount of pus be sufficiently large. It has 
happened that the pus has escaped from the cranium by the 
nose or ear. A lady now under my charge experienced 
this result several weeks since ; a large quantity of purulent 
matter making its exit through the posterior nares. She is 
still alive, in full possession of her reasoning faculties, and 
her articulation perfect, but with the loss of sight in both 
eyes, paralysis of the right side of the face, the left arm, 
and leg, and suffering the most intense and constant pain 
in her head. The seat of the lesion is probably partly in 
the right half of the pons Yarolii. The suppurative ac- 
tion is doubtless still going on, and I regard her death as 
inevitable. 

The substance of the brain in contiguity with the abscess, 
as already stated, undergoes disintegration. This is in the 
nature of softening. 

CHRONIC CEREBRAL ABSCESS. 

Suppurative inflammation of the brain, terminating in 
the formation of abscess, may be of a chronic character, the 
course of the disease extending over several months. This 
is especially apt to result from disease of the internal 
ear. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 255 



Cases have been reported by Abercrombie, 1 Lallemand, a 
Toynbee, 3 Ribiere, 4 and others, and three have come under 
my own observation. 

Chronic abscess may also result from injuries of the 
brain or skull, and from suppuration set up around a clot 
due to extravasation of blood. 

As in the acute form of the disease, there are no very 
characteristic symptoms indicating the formation of abscess. 
Indeed, in some cases there are no symptoms at all referable 
to the brain for the whole period of the course of the dis- 
ease, till a short time before death. A great part of a lobe 
may be destroyed, and even both anterior lobes almost en- 
tirely obliterated, and the patient continue to manifest his 
ordinary degree of intelligence. 

Ribiere 6 has collected a number of interesting cases, sev- 
eral of which almost overturn some of our most definite 
ideas of cerebral physiology and pathology. Thus, he cites 
(Observation II.) the case of a man who entered the Hopital 
de la Pitie, January 27, 1866. The patient was depressed, 
answered questions with difficulty, and complained of a 
violent pain in the head. The symptoms were supposed to 
indicate the existence of typhoid fever. Two days subse- 
quently a purulent discharge was noticed from the right ear, 
and, the pain in the head persisting, the diagnosis was 
changed to suppurative otitis, with probable caries of the 
petrous portion of the temporal bone. Leeches were applied 
behind the ears and purgatives administered, after which 
the patient felt so far well that he determined to leave the 
hospital. He went to work again, and, on the 12th of Feb- 
ruary, attended a ball. The following morning, pus, mixed 

1 On Chronic Inflammation of the Brain and its Membranes. Edinburgh 
Medical and Surgical Journal, voL xvi., 1818, p. 265, et seq. 
8 Op. cit., p. 80, et seq. 

3 The Diseases of the Ear, etc., Philadelphia, 1860. 

4 Des Abces de l'Encephale Consecutifs a la Carie du Rocher. These de 
Paris, 1866. 

Op. cit. 



256 DISEASES OF THE BRAIN. 

with blood, was discharged from the right ear, and, the ten- 
dency to stupor reappearing, he again presented himself at 
the hospital. It was then ascertained that the flow from 
the ear had begun several years previously, but had ceased 
for the two years immediately preceding his first entrance 
into the hospital. 

On the 14th he was in a state of not very intense stupor, 
since he was able to complain of the pain in the head ; his 
pulse was 60, full and hard, and pus was passing from the 
right auditory canal. By the 16th of February the stupor 
had increased. There was no paralysis, deviation of the 
face, nor alterations of sensibility. The patient understood 
questions put to him, but answered slowly and imperfectly. 
The eyelids were closed, light appeared to be unpleasant, 
and the purulent flow still continued. He died at nine 
o'clock that night, without convulsions. 

The post-mortem examination of the head revealed the 
following condition : 

The external auditory canal was filled with desiccated 
purulent matter; there was neither abscess nor abnormal 
redness about the ear. 

The superior longitudinal sinus was gorged with blood, 
the veins were black and dilated ; the brain appeared con- 
gested, but a yellow tint of the right cerebral lobe was 
noticed. At the inferior face of this lobe, where a rupture 
had occurred in handling the brain, a quantity of pus esti- 
mated at one hundred grammes (about three ounces) flowed 
out. This was of a greenish color, and of offensive odor. 
The cavity left was about the size of a hen's egg, and was 
bounded by red, indurated, and thick walls. The pus, which 
during life had flowed from the auditory canal, had not 
come from the abscess, but from the carious petrous portion 
of the temporal bone. 

Around the abscess the substance of the brain was yel- 
low and softened. Three-fourths of the middle and poste- 
rior lobes were infiltrated with pus and softened in texture. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 257 

The capillaries were not visible to the naked eye ; the con- 
volutions of the island of Reil were not recognizable, and 
the neighboring convolutions were not now distinct. The 
corpus striatum of the right side was healthy in its anterior 
fourth. In the rest of its extent it was softened. The optic 
thalamus was also softened, as were likewise the roots of the 
optic nerve. We see that, in this case, as Ribiere remarks, 
a considerable abscess had destroyed, in great part, the cor- 
pus striatum and optic thalamus, and that, nevertheless, the 
patient had been able to' work till within a few days of his 
death, and was so slightly paralyzed as to be able to attend 
a public ball. Aside from a certain hebetude, the intellec- 
tual faculties were not deranged. 

Another patient observed by Eibiere presented an entire 
absence of cerebral troubles, no paralysis, no contractions, 
no convulsions ; the sensibility was intact, and the intelli- 
gence was active. ^Nevertheless, there was a degree of stu- 
pidity expressed in the countenance, and the expression was 
dull. 

Still there is almost always some pain in the head, which 
may be irregular as regards its location and character, or 
may be confined to one particular spot. 

In one of the cases under my observation, there was very 
acute pain, almost constant nausea or vomiting, a strong 
tendency to coma, and hemiplegia of the left side, coexisting 
with purulent discharge from the right ear. The patient, 
who had a short time previous suffered an attack of scarlet 
fever, to which the ear-trouble was clue, died suddenly coma- 
tose, but without convulsion. Examination after death 
showed the existence of caries of the petrous portion of the 
temporal bone, and an abscess containing about two ounces 
of pus in the middle lobe of the right hemisphere. The 
right corpus striatum was softened in about half of its ex- 
tent. 

In the other case there had been profuse discharge from 
the right ear for several vears, unattended bv any cerebral 
11 



258 DISEASES OF THE BRAIN. 

symptoms except occasional pain and headache, which were 
supposed by the family to be due to gastric derangement, 
and for which no medical advice was ever asked. One morn- 
ing the patient, a young lady, twenty years of age, was sud- 
denly roused from bed by an alarm of fire. In her hurry to 
dress herself, and in the confusion of the moment, she struck 
her head against the edge of an open door. She immediate- 
ly felt a severe pain in the head and cried out, but almost 
instantly sank down to the floor in a stupor, from which she 
never emerged, death ensuing within Hvq hours. On remov- 
ing the calvarium a large extravasation of pus was discov- 
ered under the arachnoid, covering the right hemisphere, 
and it was discovered that an abscess, the cavity of which 
was as large as a small orange, had occupied the middle lobe, 
and had ourst through the convex superior surface by rup- 
turing the cerebral substance. The petrous portion of the 
temporal bone of that side was carious, and communicated 
by several very small openings with the abscess. 

When speaking of cerebral haemorrhage, I have referred 
to another case in which there was abscess of the cerebellum, 
produced by injury of the skull. In this instance there were 
notable symptoms, vertigo, convulsions, nausea, vomiting, 
and violent pain in the back of the head. At first there was 
no paralysis, but the patient subsequently became paraple- 
gic, and died in convulsions. Examination after death dis- 
closed an abscess, the cavity of which comprehended nearly 
the whole of the left lobe of the cerebellum. 

Although recovery from chronic abscess of the brain 
never takes place, yet life is often prolonged for several 
years, even when there may be marked symptoms of cere- 
bral disorder. And then when death occurs it is generally 
suddenly, with or without obvious exciting cause. 

Treatment. — The treatment of acute suppurative ence- 
phalitis is altogether palliative. Symptoms, such as pain, 
vertigo, and vomiting, may be controlled to a certain extent. 
I have derived considerable benefit from the extract of In- 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 259 

dian hemp, given in conjunction with the bromide of potas- 
sium. The doses of Squires's extract may range from half a 
grain to two grains three times a day, with from thirty to 
forty grains of the bromide, either of potassinm or sodium. 
The pain and irritability of the nervous system are greatly 
lessened by these remedies, and thus the patient's condition 
rendered more tolerable. 

"When there is reason to suspect a syphilitic origin, mer- 
cury and iodide of potassium may be administered theoreti- 
cally with some prospect of success, but practically with 
very little benefit. The medicines shonld be given in fre- 
quently-repeated doses — calomel being the preferable mer- 
curial — so as to bring the system, as soon as possible, under 
their influence. 

Bloodletting, local and general, blisters, tartar-emetic, 
and other measures calculated to depress the powers of the 
system, are worse than useless. 

In suppurative disease of the internal ear, probably due 
to caries of the petrous portion of the temporal bone, pre- 
ventive measures against chronic abscess may do something. 
Leeches applied to the mastoid process, and blisters behind 
the ear, are indicated, and mercury with iodide of potassium 
will afford a chance of a beneficial result. The solution of 
the bichloride of mercury with iodide of potassium in water 
constitutes an eligible preparation. The flow of pus shonld 
be facilitated, and the propriety of trephining the mastoid 
cells may be a question for consideration. The manage- 
ment of injuries, with a view to preventing abscess, is to be 
conducted upon very obvious surgical principles. 



CHAPTER XII. 

DIFFUSED CEREBRAL SCLEROSIS. 

By diffused cerebral sclerosis is to be understood a mor- 
bid condition of some part of the brain characterized by 
induration and atrophy of the tissue, and not distinctly 
circumscribed except by the anatomical limits of the region 
affected. 

It is not a disease which can be recognized with any 
great degree of certainty or even of probability during life. 
Is is, however, a well-marked pathological condition, giving 
rise to very prominent symptoms. Of late years the affec- 
tion has not been much noticed, except incidentally, by a 
few writers of special treatises — though, under the name of 
u induration of the brain," it received considerable attention 
many years ago. 

The symptoms by which it is characterized are by no 
means peculiar to it, though, when taken collectively, they 
give us some reason to diagnosticate sclerosis as their cause. 
A number of cases have come under my observation in 
which the lesion was probably diffused cerebral sclerosis ; 
but I have never had the opportunity of verifying my diag- 
nosis by post-mortem examination. The remarks, therefore, 
which I shall make on the morbid anatomy will mainly be 
based upon the studies and observations of other writers. 

Symptoms. — The symptoms of diffused cerebral sclerosis, 
like so many other brain-affections, are connected with the 
mind, with sensibility, and with the power of motion. It 
generally makes its appearance during infancy, and produces 



DIFFUSED CEREBRAL SCLEROSIS. 261 

an arrest of development in the part of the brain affected, 
and consequently in certain parts of the body. The initial 
phenomena are those of congestion and inflammation, dur- 
ing the course of which epileptic convulsions frequently 
ensue. These may be few in number, and may cease in a 
few days, or they may be very frequently repeated and last 
for several years, or during the whole life of the patient. 
The mind remains undeveloped, speech, if already acquired, 
often becomes imperfect, and, if not yet present, may never 
be commenced. The limbs, usually only on one side of the 
body, become paralyzed, and do not grow with the same 
rapidity as those on the sound side. Contractions are very 
apt to take place, from the fact, probably, that the normal 
degree of antagonism between the muscles is destroyed, and 
that those not so much paralyzed as others draw the limbs 
in the direction of their action. It is quite common, there- 
fore, in the affection under consideration, to And the fingers 
drawn into the palm of the hand, the wrist flexed on the 
forearm, the forearm on the arm, and the arm drawn back- 
ward by the action mainly of the latissimus dorsi. In the 
lower limbs, club-feet are produced in a similar manner. 

It is not uncommon, too, to find one or more senses weak 
or altogether lost, and the general sensibility of the body di- 
minished on one side. 

The urine and fasces are often passed involuntarily, or 
else the patient, from never having acquired a sense of pro- 
priety or cleanliness, passes them whenever he chooses, at 
any time or place. 

With this general idea of the symptoms, I proceed to re- 
fer somewhat at length to its history, in the course of which 
I shall quote several cases in illustration of its progress. 

The first to direct specific attention to the disease under 
consideration was M. Pinel, 1 the younger, who, in a memoir 
read before the French Academy of Sciences, May 27, 1822, 

1 Recherches d'Auatomie Pathologique sur l'Endurcissement du Systerae 
Nerveux. Journal de Physiologie de Magendie, t. ii., 1822, p. 191, et seq. 



262 DISEASES OF THE BRAIN. 

brought forward several cases in illustration of what he de- 
nominated " induration of the brain." I quote the first case 
in full as a typical example of the affection : 

Beler, aged eighteen years, an idiot from birth, was ad- 
mitted into the Salpetriere Hospital, June 1, 1821. The 
patient was paralyzed in the left arm and leg. She could 
not use this arm, for the hand was strongly flexed on the 
forearm, and could not be extended. She walked with great 
difficulty, dragging the left leg. Her intellectual faculties 
were very much restricted; she comprehended only the 
questions which were addressed to her relative to her health, 
her intelligence not extending beyond that point. She had 
also great difficulty in articulating the words yes and no, 
which were the only words she could speak. She had no 
particular habit, was always calm and tranquil, and had to 
be anticipated in all her wants. She was subject to occa- 
sional attacks of epilepsy ; but, when the paroxysms came 
on, she had fits almost without intermission for thirty or 
forty hours. They returned about every twenty-five days. 
On the 4th of December, 1821, the patient was taken with 
a series of epileptic fits, almost continual in character, which 
lasted during four days, the paroxysms succeeding each other 
with inconceivable rapidity. During these continuous con- 
vulsions the right limbs were affected with violent move- 
ments. The left limbs, which had been paralyzed for a long 
time, were also strongly agitated, and the general sensibility 
was abolished. The face was red, the eyes were twisted, 
the dejections were passed involuntarily, the pulse was fre- 
quent and irregular, and the respiration unequal and jerk- 
ing. The patient died on the fourth day, without there 
having been any remission in the symptoms. 

Post-mortem Examination. — " General marasmus ; re- 
markable emaciation of the paralyzed limbs. The cranium 
was thick, eburnated, and very hard to break. The me- 
ninges were pale and healthy. The right lobe [hemisphere] 
of the brain was very much smaller than the left, it was 



DIFFUSED CEREBRAL SCLEROSIS. 263 

atrophied ; the convolutions were almost obliterated and 
very small, especially in the frontal and occipital regions. 
They were large and deep in the inferior part. The corti- 
cal substance was thicker than it generally is ; the lateral 
ventricle was very small and dry. The substance of the 
brain, throughout the whole extent of this right lobe [hemi- 
sphere], and notably above the ventricle, was of remarkable 
hardness, and it was torn with difficulty by the fingers, the 
tissue separating in longitudinal bands which converged 
toward the corpus striatum. 

" The left lobe [hemisphere] of the brain, much more 
developed than the right, was of the softness and consist- 
ence of the healthy brain-tissue, and this condition made 
the alteration in the right lobe [hemisphere] more obvious." 

The rest of the description refers to other organs. 

In regard to this case, M. Pinel remarks that to the 
pathological condition, the loss of the power of motion in the 
whole of one side, the almost complete annihilation of the 
iatellectual faculties, and probably the epileptic fits, are to 
be ascribed. The condition — which is frequent with idiots, 
but of which it is often difficult to estimate all the various 
symptoms — is ordinarily revealed less by the paralysis of 
the limbs than by the distortions which it determines in the 
feet and the hands. Three other cases are adduced, in one 
of which the cerebellum was also in part indurated. M. 
Pinel, as the result of his observations of the morbid anat- 
omy, states that the nervous tissue resembles a compact in- 
organic mass ; its consistence and density are those of hard- 
boiled white-of-egg ; the cerebral substance is atrophied ; it 
appears entirely deprived of blood-vessels — the eye perceiv- 
ing no trace of capillaries. The induration appears to affect 
more particularly the medullary substance than the gray 
substance ; it was never observed in this last-named tissue. 

Griesinger, 1 under the name of " diffused hypertrophy 

1 Die Pathologie und Therapie der psychischen Krankheiten, Zweite Au- 
flage, 1861, p. 301. Also New Sydenham Society translation, p. 359. 



264: DISEASES OF THE BRAIN. 

of the connective tissue of the brain," describes the affection 
now under consideration, and refers to an interesting case 
reported by Isambert, 1 in which a microscopical examina- 
tion of the altered tissue was made. It occurred in an 
idiotic child, two years of age. The ventricular walls, the 
great ganglia, the pons and peduncles, were solid and hard ; 
their tissue was elastic, like caoutchouc ; the nerve-tubes in 
the white substance were almost completely destroyed and 
an amorphous granular substance occupied their place ; 
there also existed newly-formed fibrous connective tissue. 
In regard to such cases, Griesinger remarks that, when we 
are told that a hitherto healthy and well-developed child, 
about the period of dentition, or during the second or third 
year, suddenly became feverish, was attacked with convul- 
sions and delirium, fell into a slightly soporific state, and 
soon afterward apparently recovered, but with the intellect- 
ual and physical development checked, the condition may 
be due to one of two morbid processes : either there are 
slight congestion and inflammation of the membranes, or 
there is encephalitis, which, after passing out of the acute 
stage, suspends further development in the affected parts. 
The mind, therefore, ceases to expand ; walking, if begun, 
is arrested ; speech remains as it is, or is altogether lost ; 
one side of the body does not grow so fast as the other ; 
and convulsions, paralysis, and contractions, are present. 

A case in point, referred to by Griesinger, I quote from 
Calmeil : 2 

"M. Alfred, born at Havre, single, aged twenty-two 
years, came to the Bicetre, where he resided twenty-two 
months : he had been an invalid since infancy. 

" Until about three years of age, he had exhibited no pe- 
culiarity as regarded intelligence — resembling other children 
of his years. 

" At this period, however, he was attacked with measles, 

1 Compt. rend, et Mem. de la Societe de Biologie, t. ii., 1856, p. 9. 

8 Traite des Maladies Inflammatoires du Cerveau, Paris, 1859, t. ii., p. 411. 



DIFFUSED CEREBRAL SCLEROSIS. 265 

which was considered mild in form, and from which he had 
nearly recovered, when he was seized with a succession of 
severe eclamptic paroxysms. During twelve hours, it was 
impossible to rouse him from the coma, and general convul- 
sions were present almost without interruption. 

" The day after, it was perceived that he was deaf, blind, 
and incapable of articulating the least sound ; the convul- 
sions had ceased. 

" At the end of fifteen days he recovered his hearing ; 
after a year he could say a few words ; but the retinge con- 
tinued insensible to impressions of light. 

" It was now perceived that he walked with a certain 
degree of difficulty, and that he could hardly use the right 
hand. At times, also, he lost consciousness, but without 
falling, and it was subsequently recognized that these at- 
tacks were epileptic. 

" Until the age of thirteen, the intelligence of M. Alfred 
underwent scarcely any development, and he remained im- 
becile notwithstanding all the efforts made for his improve- 
ment. He nevertheless acquired a knowledge of a certain 
number of words, and he could make himself understood 
whenever he had a want to gratify. 

" At the age of nineteen he presented the symptoms of 
an almost complete state of idiocy. He comprehended 
some things, and could imperfectly articulate a few words. 
He was not evilly disposed, but he was incapable of attend- 
ing to his person, and even of eating without assistance. 

" He could take a few steps by supporting himself against 
the wall, on articles of furniture, or a cane, but he dragged 
his feet on the ground, and his right leg appeared to be 
weaker than the left. The right arm was contracted and 
almost immovable. Tactile sensibility was not affected 
anywhere. He did not appear to perceive objects placed 
immediately before his eyes, and the pupils were dilated 
and insensible to the sudden accession of light. As regard- 
ed the bladder and rectum, he evacuated them without 



266 DISEASES OF THE BKAIN. 

seeming to exercise the least restraint of cleanliness or pro- 
priety. 

" The epileptic paroxysms occurred with long intervals 
between them, and presented no characteristics worthy of 
special mention. The complexion was pale, and the body 
emaciated and notably weak. 

"During the month of January, 1827, there was fre- 
quent cough, combined with abundant expectoration, diar- 
rhoea, and other symptoms of phthisis." He died in Feb- 
ruary of the same year. 

Autopsy. — The whole of the right side of the body was 
much less developed than the left side. The right arm and 
leg were especially emaciated and thin. " The face was free 
from distortion, and the cranium, without being deformed, 
was small and very narrow. The greater part of the cra- 
nium was abnormally thick, and contained an excessive 
amount of calcareous matter. 

" The dura mater was without change, and did not ad- 
here to the osseous surfaces. 

" A very considerable quantity of serum was infiltrated 
into the meshes of the pia mater — principally toward the 
middle and convex surface of the two cerebral hemispheres. 
The pia mater was thickened, but was not adherent to the 
convolutions. 

" The left cerebra] hemisphere was notably smaller than 
the right ; the posterior lobe being particularly remarkable 
for its diminution. The convolutions were flattened, and 
were as thin as the blade of a knife, were resistant to the 
touch, and were of a clear yellow color. The middle and 
anterior lobes were neither of them of ordinary size. 

" The posterior lobe of the right hemisphere was less de- 
veloped than in a healthy brain, but the number of atro- 
phied convolutions was small. 

" On cutting into the left posterior lobe with a bistoury, 
its tissue was found to be white, compact, homogeneous, 
and very resistant. It might be said that the cerebral sub- 



DIFFUSED CEREBRAL SCLEROSIS. 267 

stance had become doughy, and that an element, foreign to 
its nature, gave it an excessive degree of hardness. 

" On the right, the atrophied convolutions of the poste- 
rior lobes were difficult to cut ; their structure was compact, 
but the induration of the nervous tissue did not extend 
deeply into the thickness of the lobe. 

" In all other parts of the brain the white and the gray 
substance, as well on the left as on the right side, were ap- 
parently, in all respects, in a healthy condition. 

" The corpora striata and the optic thalami were free 
from change, either as regarded their volume or their struct- 
ure. 

" The pons Yarolii, the tubercula quadragemina, and the 
peduncles of the cerebrum, and cerebellum, were in a nor- 
mal state. 

" The spinal cord relatively, and perhaps even absolutely, 
appeared to be larger than was natural. 

" The optic nerves were atrophied, of a glossy white 
color, and very hard." 

Other cases, similar in general features, are adduced by 
Calmeil. 

In the very interesting monograph of Cotard, 1 to which 
reference has already been made, the relation of sclerosis to 
atrophy of the brain is clearly pointed out. As indicating 
a certain set of symptoms, in existence with a definite patho- 
logical state, I quote the following case, No. XXIX of his 
series : 

" C, aged fifty-eight years, an inmate of the Salpetriere 
since 1828, entered the infirmary April 25, 1865, under the 
charge of M. Charcot. 

" She gave the following information, which she said she 
had from her mother, and from other persons who had 
brought her up : At the age of eighteen months she had 
three attacks of convulsions, which left her paralyzed on 
her right side. She had never had convulsions since. She 

1 Etude sur l'Atrophie partielle du Cerveau, Paris, 1868, p. 49. 



268 DISEASES OF THE BRAIN. 

had already begun to walk when the seizures took place, but 
she did not walk again till she was three years old. 

"According to the information given by the superin- 
tendent of her ward, who had known her since her entrance 
into the hospital, her intelligence had always been weak ; 
she was incapable of attending to herself; she could read 
tolerably well, and could sign her name ; she had always 
spoken without difficulty. 

" She had been employed with coarse sewing, and had 
invariably been docile and attached to those who took care 
of her. 

" Her health had always been good, though she had, 
when about the age of twenty-five or thirty, several attacks 
of hysteria. Menstruation had been regular, and had ceased 
when she was forty-five. 

" For about a year the patient had been the subject of 
frequent attacks of vomiting, or of epigastric pain. At the 
time of her admission to the infirmary, she was very much 
emaciated and very cachectic. 

" Her intelligence did not appear to have been recently 
enfeebled ; she could read, sign her name, and speak with- 
out difficulty. 

" Her senses seemed to be intact ; sight was good in both 
eyes, and the pupils were equal. There was no facial pa- 
ralysis, and the tongue was protruded straight. 

" The right arm was emaciated, atrophied, and contract- 
ed ; the forearm was pronated and semi-flexed on the arm ; 
the hand was flexed on the forearm, and inclined toward the 
ulnar side ; the fingers were flexed in the palm of the hand, 
particularly the ring and little fingers ; the index-finger was 
semi-flexed, and the thumb was extended. 

" It was possible, without very great force, to bring the 
several parts of the limb almost into a state of extension, 
but, as soon as it was left to itself, it resumed its habitual 
position. The patient could execute a few movements with 
the shoulder and the elbow, but the wrist was absolutely 



DIFFUSED CEREBRAL SCLEROSIS. 269 

paralyzed, and the fingers could only be moved to a very 
limited extent. 

"The right leg was less atrophied, and there was no 
other deformity than a talipes equinus. The patient walked 
with a cane. 

" The sensibility of the right side was intact, and no 
very notable difference of temperature was observed be- 
tween the healthy and the paralyzed sides. 

" The patient died May 17th, after symptoms of acute 
peritonitis. 

" Autopsy. — Cancer of the stomach, circumjacent ab- 
scess, purulent peritonitis. 

" ]STo exterior deformation of the cranium ; on the left 
side its walls were thick, doubly and triply so at some 
points ; the frontal sinus extended to the left of the mesial 
line, and communicated with a large cavity situated in the 
orbital arch, which was composed of two thin osseous la- 
mellse. 

" The left middle fossa was smaller than the right, and 
the right cerebellar fossa was smaller than the left. 

" The dura mater being incised, a large quantity of serum 
escaped from the left side. The left hemisphere was very 
small, shrivelled, and in length and breadth scarcely two- 
thirds the corresponding dimensions of the right hemisphere. 
The convolutions were pressed together, were hard, and of 
a whitish color. 

" On the external face of the middle lobe, behind the 
posterior marginal convolution, and on the prolongation of 
the fissure of Sylvius, there was a deep depression running 
upward and backward, and three or four centimetres in 
length. At the bottom of this depression the convolutions 
were reduced to little ridges, which were hard, and of a yel- 
low color. The ventricle was considerably dilated ; the cor- 
pus striatum did not appear to be perceptibly diminished in 
volume, but the optic thalamus was hardly one-fourth as 
large as that of the opposite side. There was considerable 



270 DISEASES OF THE BRAIN. 

atrophy of the left crura of the fornix, and of the mammary 
tubercle. 

" The olfactory and optic nerves of the left side were 
apparently healthy ; the tubercula quadrigemina were not 
atrophied. 

" The right hemisphere was healthy. 

" The right hemisphere of the cerebellum and the middle 
cerebellar peduncle of the same side were atrophied." 

Examined with the microscope, the indurated convolu- 
tions of the left hemisphere presented an enormous quantity 
of amyloid corpuscles and of nuclei of connective tissue. 

The following cases I select from others of similar char- 
acter which have occurred in my own practice : 

Case I. — J. S., a boy, aged five years, was brought to me 
in the autumn of 1869, to be treated for epilepsy. The par- 
oxysms occurred several times a day, and had originated 
when the child was two years of age, in consequence, as the 
mother thought, of a fall. 

At that time he could say a number of words, and was 
rapidly learning to talk ; his intelligence was good, and he 
had been walking for several months. 

But after the first convulsion he ceased to speak and to 
walk, though he continued up to the time I first saw him to 
give his attention to very striking objects, such as noisy tops, 
bright-colored articles, and, above all, music and soldiers. 
During this period he had at least six exacerbations, charac- 
terized by pain in the head, repeated convulsions, and coma. 

When he was about two years and a half old it was ob- 
served that he did not move the left arm and leg so freely as 
the right, and soon afterward he ceased to move them at all. 
The toes then began to be drawn under the sole of the 
foot, and the heel was raised. Then the leg became flexed 
on the thigh, and soon afterward the fingers of the left hand 
and thumb were gradually bent so as to press strongly against 
the palm. The wrist followed, and then the forearm. Both 
limbs were greatly atrophied. 



DIFFUSED CEREBRAL SCLEROSIS. 271 

When lie came under my examination he was having epi- 
leptic convulsions, both of the grand and petit rnal, every 
day. There was no deformity of the skull, though it was 
certainly small for his age. His mind was feeble, and he 
did not give attention to any remarks made to him, but 
bright objects at once attracted his gaze, and he made efforts 
to get hold of them. 

I examined the fundus of the eyes with the ophthalmo- 
scope, and discovered an ansemic condition of the retinge and 
atrophy of both optic disks. 

I gave it as my opinion that the child was suffering from 
diffused cerebral sclerosis, involving the left hemisphere; 
and that there was scarcely any prospect of material ameli- 
oration in his mental or physical condition. 

Case II. — A female, aged eight years, entered the New 
York State Hospital for Diseases of the Nervous System, 
June, 1870, having previously been a patient at my clinic at 
the Belle vue Hospital Medical College. When quite an in- 
fant she had suffered from epileptiform convulsions, which 
had been almost immediately followed by paralysis of the 
right upper and lower extremities. The convulsions recurred 
at short intervals, and atrophy of the paralyzed limbs, with 
contractions of the fingers, hand, and forearm, supervened. 
She learned to walk, however, quite well, and also to talk 
without any very notable defects. 

Her mind was weak, and she was extremely silly in her 
behavior ; she had never learned to read. 

Under the use of the bromide of potassium her epileptic 
paroxysms ceased, but the contractions and atrophy of the 
right arm resisted treatment by galvanism and mechanical 
appliances. The leg acquired much more power under the 
treatment than it had previously possessed. 

Case III. — W. W., a gentleman, aged forty-three, came 
to me, December 11, 1869, to be treated for what his physi- 
cian and friends regarded as softening of the brain. 

About six months previously he had experienced, on 



272 DISEASES OF THE BRAIN. 

awaking in the morning, great difficulty in extending the 
left hand and fingers, and through the whole day there was 
a decided tendency manifested for the latter to close and the 
hand to be flexed upon the forearm ; and this gradually, day 
after day, became stronger, till at last neither the hand nor 
fingers could be extended. 

Then the corresponding lower extremity became involved 
in a similar manner, and about a month after noticing the 
first symptom he had an epileptiform convulsion, and this 
was repeated twice the following day. Since then the fits 
have occurred at intervals of four or &ve days. With the 
contractions in the limbs of the left side there was gradual- 
ly-advancing paresis until, when he came under my observa- 
tion, both arm and leg were almost completely paralyzed. 
Atrophy of both extremities was present to an extreme de- 
gree, and sensibility and electro-muscular contractility were 
almost entirely abolished. 

His mind was also notably impaired. He laughed im- 
moderately at every question I put to him, and had a de- 
cided expression of imbecility. His speech was not affected 
to any remarkable degree, except as regarded extreme slow- 
ness of utterance. He had previously to his illness been a 
ready and quick speaker. My diagnosis was diffused cere- 
bral sclerosis, and I gave an unfavorable prognosis. The 
treatment, which will be considered under its proper head, 
was, however, successful to a very considerable extent. 

It will be seen, from the foregoing account of the symp- 
toms, that diffused cerebral sclerosis is characterized mainly 
by weakness of intellect, paralysis, and muscular contrac- 
tions. 

Causes. — The predisposing causes of the affection under 
consideration are not thoroughly understood. The disease 
appears to be much more frequent in infancy, although it 
lasts to the period of old age, and sometimes originates at an 
advanced time of life. 

The exciting causes are likewise imperfectly known. In- 



DIFFUSED CEREBRAL SCLEROSIS. 273 

juries of the skull from falls or blows and hemorrhagic cysts 
appear to have some influence in originating the disease, but 
more generally it is developed, so far as we can perceive, 
spontaneously. 

Diagnosis. — The diagnosis of diffused cerebral sclerosis 
must always be more or less uncertain, for the reason 
that the symptoms are met with in other very different 
affections. In children a similar set of phenomena may be 
the consequence of arrest of development in the brain with- 
out any alteration of its structure recognizable by our means 
of observation. In the case of an idiotic child affected with 
convulsions, hemiplegia, and muscular contractions, I found, 
on post-mortem examination, the left hemisphere markedly 
smaller than the right, but I could detect no change of any 
part of its structure. 

Symptoms like those met with in diffused cerebral scle- 
rosis may result from brain-tumors of various kinds. 

In adults the disease is readily discriminated from cere- 
bral haemorrhage and embolism by the gradual character of 
its advance, and by the mental symptoms being more strong- 
ly pronounced. But from softening the diagnosis cannot 
always be made out, and an opinion must be formed from 
the history and phenomena in each individual case. 

From thrombosis the diagnosis is equally difficult. Per- 
haps the distinction may be made both as regards softening 
and thrombosis by the facts that, though contractions are 
met with in both these diseases, they are not such invariable 
accompaniments as they are in diffused cerebral sclerosis, 
and that they are never, as occasionally in the latter affec- 
tion, a primary symptom. 

Prognosis. — The prospect of complete recovery is very 
gloomy, and even amelioration has hitherto been regarded 
as out of the question. I am inclined, however, to think, as 
the result of my own experience, that the condition of pa- 
tients, apparently suffering from the affection in question, 
may be decidedly improved by suitable medical treatment. 
18 



274: DISEASES OF THE BRAIN. 

I have several times succeeded in arresting the convulsions, 
strengthening the mind, increasing the strength and sensi- 
bility of the paralyzed members, and relaxing the contrac- 
tions. My success has been much more decided in cases 
which had originated late in life — probably, for the reason 
mainly that the disease was seen earlier in its course. 

Morbid Anatomy. — This division of the subject has al- 
ready been considered incidentally, to some extent, in the 
remarks made under the head of symptoms, and in the de- 
tail of cases quoted. 

The most obvious feature detected by ordinary observa- 
tion is the increased hardness and density which the cere- 
bral tissue has acquired. This generally occupies a consid- 
erable portion of one lobe, or may extend through the whole 
of it, or may even affect a whole hemisphere. It is not dis- 
tinctly circumscribed, but diminishes in intensity from the 
centre to the periphery, and, according to Pinel, never in- 
vades the gray substance. 

The increased density is attended with atrophy when the 
disease affects the adult, and with atrophy and arrest of de- 
velopment when children are its subjects. 

In order to understand the essential nature of the mor- 
bid process which causes the brain to become indurated, a 
few words in regard to cerebral histology are necessary. 

Besides the nervous tissue of the brain, there is another 
anatomical element present which fulfils the function of 
binding the cells and fibres together, and giving the whole 
substance its normal degree of consistence. According to 
Yirchow, 1 this, although analogous to, is different in some 
respects from ordinary connective tissue. He gave to it the 
name of neuroglia or nerve-cement. 

Diffused cerebral sclerosis consists in the hypertrophy or 
increased formation of this tissue, and the atrophy or disap- 
pearance of the proper nervous substance. Atrophy of the 
brain may, however, be due to other causes than sclerosis, 

1 Cellular Pathology, Chance's translation, London, 1860, p. 277. 



DIFFUSED CEREBRAL SCLEROSIS. 275 

as in the case reported with great minuteness by Schroeder 
van der Kolk, 1 and several of those cited bj Lallemand, 3 
Turner, 3 and other writers. 

Pathology. — The symptoms which result from diffused 
cerebral sclerosis are those which we might expect to be the 
consequence of a condition which essentially consists of a 
disappearance of that part of the brain-tissue capable of pro- 
ducing or transmitting nervous force, and the substitution 
of another histological element which is of secondary im- 
portance. They all indicate deficient cerebral power. It 
is with the brain as with a muscle undergoing atrophy : less 
force results from its action in correspondence with the ad- 
vance of the process by which the characteristic anatomical 
elements disappear. 

Doubtless, if we had the opportunity of more thorough 
study of the symptoms of diffused cerebral sclerosis, and 
comparing them with the condition of the brain as found by 
post-mortem examination, we should find that they varied 
considerably in character, according to the part affected, 
and we should probably have reason to believe that the 
nervous cells which had disappeared — motor, sensitive, or 
trophic — tt'ere in exact pathological relation with the symp- 
toms observed. This special point has been well studied by 
MM. Duchenne de Boulogne and Jouffroy, 4 in a recent pa- 
per, devoted to a somewhat different disease, and to which 
I have recently been enabled to add a few important data. 

Treatment. — This division of the subject has scarcely re- 
ceived any attention from authors. My experience, how- 
ever, has sufficed to convince me that we can occasionally 
improve the condition of the patient. 

1 A Case of Atrophy of the Left Hemisphere of the Brain, etc. New Syd. 
Soc. trans. London, 1861. 

2 Op. cit. 

3 De l'Atrophie partielle ou unilateral du Cervelet, etc. Paris, 1856. 

4 De l'Atrophie Aigue et Chronique des Cellules Nerveuses de la Moelle et 
du Bulbe Rachidien, etc. : Archives de Physiologie, No. 4, Juillet et Aout, 18*70, 
p. 499. 



276 DISEASES OF THE BRAIN. 

If there are epileptic convulsions, they may be prevented 
by the administration of the bromide of potassium in doses 
of at least twenty grains, three times a day, to an adult. 
Larger doses may be necessary. On the cessation of the 
convulsions, it will sometimes be found that the intelligence 
at once begins to be developed. 

The paralysis and contractions may sometimes be less- 
ened by the persistent use of both the induced and primary 
galvanic currents. The first named will often in the begin- 
ning fail to act upon the muscles, in which case the latter 
should be employed. This is always better for the contract- 
ed muscles than the induced current. For the relief of the 
paralysis it should be interrupted, for the relaxation of con- 
tractions it should be constant. 

As regards the central lesion, I think it may occasionally 
be reached, when it has not had time to become very exten- 
sive or profound. And the best and really only means I 
know of are the primary galvanic current passed through 
the brain, and the administration of the chloride of barium. 

In using the galvanic current, the electrodes — wet 
sponges — should be applied over the mastoid processes, and 
kept there for a period not exceeding three minutes. Fif- 
teen of Smee's cells will afford a current of sufficient inten- 
sity. The application should be made about every alternate 
day. 

The chloride of barium may be given in doses of about a 
grain three times a day. I usually administer it in solution, 
according to the following formula: 1$. Barii chloridi 3j, 
aquse dest. § j, M. ft. sol. ; dose, gtts. xij three times a day. 

I am unable to say that these measures have actually re- 
moved the supposed sclerosis of the brain, and caused the 
reformation of the atrophied cells, but I am very sure that 
symptoms such as are attendant upon diffused cerebral scle- 
rosis have several times been measurably dissipated by its 
influence. Thus, in the third case mentioned as occurring 
in my practice, the mind improved, the epileptic paroxysms 



DIFFUSED CEREBRAL SCLEROSIS. 277 

ceased, the contractions were relaxed, the paralysis lessened, 
the affected limbs increased in size, and the further progress 
of the disease was arrested. At the present date (December 
30, 1870) the gentleman is able to take care of himself, 
to walk tolerably well, and to use the formerly-paralyzed 
arm for many purposes. In three other cases a like treat- 
ment has been productive of almost as marked a degree of 
benefit. 



CHAPTEE XIII. 

MULTIPLE CEREBRAL SCLEROSIS. 

In multiple cerebral sclerosis the lesion involves several 
parts of the same ganglion, and consists of plates or nodules 
of sclerosed tissue scattered throughout its substance. 

It is only of late years that the affection in question has 
been partially recognized as a distinct pathological condi- 
tion associated with certain symptoms. These symptoms 
were formerly, and still are to a great extent, confounded 
with other groups similar in several prominent features, but 
different altogether in anatomical relations, normal and ab- 
normal. 

Thus, under the designation of paralysis agitans, were 
comprehended the phenomena due to multiple cerebral 
sclerosis, multiple cerebro-spinal sclerosis, and muscular 
agitation general or local — the result of very dissimilar le- 
sions, or without discoverable morbid changes of any kind 
— the one symptom of tremor sufficing to bind them to- 
gether. Even by late writers the distinction is not clearly 
made out. 

It is, in the present state of our knowledge, impossible 
to say in all cases what part of the intra-cranial mass is 
affected. Still, we are not altogether without data on this 
point, and an attentive consideration of the symptoms will 
often, at least, enable us to say what ganglion of the en- 
cephalon is the main seat of the lesion. But, mindful of the 
fact that this work is intended to be practical, I shall not 
venture to deal with pathological refinements, but will point 



MULTIPLE CEREBRAL SCLEROSIS. 279 

out, with as much succinctness as possible, one form of the 
morbid process under notice — a form which I think I am 
enabled to describe, from my own observations, with con- 
siderable accuracy. That form I shall designate — 

MULTIPLE SCLEROSIS MAINLY AFFECTING THE HEMISPHERES. 

Symptoms. — Among the first symptoms noticed in this 
affection is pain, which occurs in sharp paroxysms of short 
duration. Sometimes the sensation is as instantaneous as 
an electric shock. It is rarely the case that there is any 
extreme constant pain experienced, though a feeling of ful- 
ness or constriction is occasionally more or less permanent. 

In a few cases the first observed symptom has been an 
epileptic paroxysm. 

It is not uncommon to meet with disorders of sensibility 
in other parts of the body ; and these may either be anaes- 
thetic or hypersesthetic in character. Probably the most 
common is a numbness of the ends of the fingers or toes, 
which gives the sensation of cushions when objects are 
touched, and which is generally confined at first to a single 
upper or lower extremity. Shooting pains, something like 
electric shocks, are also sometimes experienced. The prog- 
ress of the disease is almost invariably slow, and hence sev- 
eral months may elapse before any disorders of motility are 
experienced. These, however, are the next symptoms to 
make their appearance, and are generally first manifested 
by the occurrence of tremor or trembling. 

Tremor usually, but not always, is gradual in its devel- 
opment, and may be restricted to narrow limits. It may at 
first only be felt when the patient is unusually quiet, and 
has not his attention engaged. Thus a gentleman told me 
he had, for several months, only been sensible of a vibration 
in his arm when he lay down at night. It was then — from 
the description he gave me — limited entirely to the exten- 
sor indicis of the left hand, and was, in the beginning, not 
strong enough to move the finger. When I first saw him, 



280 DISEASES OF THE BRAIN. 

several years afterward, both arms and one leg were strongly- 
agitated. 

In another case, which I saw almost from the very be- 
ginning, the tremor was restricted to the same muscle for 
several months, and then gradually involved the extensors 
and flexors of the hand. And, in several other instances 
which have come under my notice, the onset was equally 
gentle. But, as 1 have said, this is not always the case. A 
gentleman consulted me in the summer of 1870, who, after 
having experienced severe darting pains in the head and 
through the limbs on the right side, was suddenly, while in 
his field overlooking some work, seized with a violent trem- 
bling of the right hand, which continued for several minutes, 
notwithstanding his efforts to prevent it. A few days sub- 
sequently, he had another accession of a similar kind in the 
same limb, and by degrees the intervals became shorter, 
until, in the space of a month, the tremor was constantly 
present except when he slept, and, when I saw him, had ex- 
tended to the whole arm and to the lower extremity of the 
same side. 

In another case, a gentleman, much addicted to excessive 
mental exertion, was awakened one morning by a violent 
agitation in his right foot. He had been under my care 
several months previously for severe headache and inability 
to sleep, for which, believing them to result from inordinate 
intellectual labor, I had recommended mental rest and horse- 
back exercise. Under the use of these measures he had ap- 
parently quite recovered, but against my advice had resumed 
his literary labors. 

He was not very confident how long the shaking of the 
foot had lasted, but thought it was not more than a few sec- 
onds. 

Several days afterward, while writing, his right hand be- 
gan to tremble slightly. He ceased his occupation, and 
rubbed his hand with the other. The tremor stopped for 
a moment only, again began, and has scarcely ever since 



MULTIPLE CEREBRAL SCLEROSIS. 281 

been absent. The whole side eventually became in- 
volved. 

The tendency of the tremor is always to extend. Be- 
ginning in an extremity or a group of muscles, or only in a 
single muscle, it goes on attacking others, until at last all 
the limbs and even the head may become affected. By 
preference, the advance of the tremor is lateral, that is, if 
an arm be first invaded, the leg of the same side next suf- 
fers, then the other arm, and then the corresponding leg. 
Usually the head is the last part attacked ; but this is not 
always so, as I have seen several cases in which the trem- 
bling began in it. 

For a long time the tremor is to some extent under voli- 
tional control. A patient, for instance, will slap his tremu- 
lous hand on his knee and for a few seconds can manage 
to keep it quiet, but it soon begins to shake again, and, 
though perhaps a second time he may arrest its movements 
by a like process, the period of rest is shorter. Any change 
of position is calculated to quiet the tremor for a time, and 
thus the patient is every few minutes moving his arms or 
legs in the attempt to get a little respite. 

It is always increased by emotional disturbance of any 
kind. A limb which may ordinarily be but slightly tremu- 
lous, will shake violently from the excitement or anxiety 
produced by making a visit to a physician. The effort to 
keep it quiet will also often increase the tremor. 

For a very considerable period after the beginning of 
the disease, the shaking ceases during sleep, but eventually 
this state affords no respite, and the patient is thus deprived 
still further of his physical strength. 

It is not often the case that the muscles of the face are 
affected very early in the disease, but they frequently be- 
come involved at a later period. In several cases I have 
seen a constant tremor in the upper eyelid of one or both 
sides, and in one instance this was the first manifestation of 
the disease. 



282 DISEASES OF THE BRAIN. 

In another very remarkable ease the first indication of 
tremor was perceived in the left eyeball, which was by 
clonic spasms of the internal rectus muscle kept in a state of 
motion producing a kind of nystagmus. The upper ]id of 
the same eye next became affected, and then the tremor ap- 
peared in the corresponding arm. The upper lip I have 
several times seen tremulous, causing thereby an indistinct- 
ness in the articulation. 

I have never observed other muscles supplied by the 
facial nerve to be involved in the tremor. 

Occasionally the lower jaw is rendered tremulous from 
the seat of the disease being at the origin or in the course 
of the fifth nerve. 

The tongue is sometimes affected with tremor, generally 
at first on only one side, and I am inclined to think that the 
muscles of the pharynx and larynx do not invariably escape. 

The tremor is not, as some authors have asserted, only 
manifested when voluntary movements are performed. This 
is probably the case at least in the first instance with multi- 
ple cerebro-spinal sclerosis, but it certainly is not in the 
purely cerebral form now under consideration. Jaccoud 1 
calls attention to the error which has been committed rela- 
tive to this point, and my own experience is uniformly in 
support of the opinion he expresses. 

The next symptom of importance to make its appear- 
ance is paralysis ; and, when the sclerosis is limited to the 
hemispheres or begins in them, it always follows the tremor. 
On this point I have insisted in my lectures to the class of 
the Bellevue Hospital Medical College, as an important in- 
dication of the fact that paralysis agitans is often a cerebral 
disease, and I am glad to find so exact an observer as Jac- 
coud 2 asserting that the paralysis is often preceded by mus- 
cular agitation or trembling. 

At first the loss of power is slight, and, like the trem- 
bling, is limited to a single muscle or group of muscles, but 

1 Traite de Pathologie interne, p. 194. 2 Op. et loc. cit. 



MULTIPLE CEREBRAL SCLEROSIS. 283 

it gradually extends until it involves the limbs of one side, 
or even of both sides. According to my observations, it 
follows the course of the trembling, no limb being ever par- 
alyzed till it has for some time been affected with tremor. 
In the face, however, the paralysis appears to be indepen- 
dent of the tremor. 

The period which elapses between the appearance of the 
tremor and the accession of the paralysis varies in different 
patients, and even greatly in the same patient. Thus some 
muscles may exhibit notable loss of power in a few weeks 
after they have begun to be agitated, while others remain 
free from paresis for many months. 

When the loss of power affects the extensors or flexors — 
especially in the former event — contractions may take place, 
as in diffused cerebral sclerosis, and the limbs are thus more 
or less distorted. The most common seat of this phenome- 
non is in the upper extremity, and it generally begins in the 
fingers, extending gradually to the wrist and elbow. But 
in some cases, even though the antagonism between certain 
groups of muscles be destroyed, there are no contractions. 
The muscles of the head, face, and trunk, do not escape. 
Strabismus, ptosis, and facial paralysis, are thus produced, 
and the muscles concerned in speech, in deglutition, and in 
respiration, likewise become involved. The sphincters, ac- 
cording to my experience, are rarely paralyzed in the early 
stages of the disease, but I have several times witnessed 
paresis of the bladder among the primary symptoms. 

A marked symptom which I have observed, and which 
can only be distinctly shown by means of the dynamograph, 
is the inability of the patient to maintain a continuous mus- 
cular contraction, for even a short period. I have noticed 
this as among the very first indications of paresis, and I am 
disposed to think it exists even before the tremor is noticed. 
Thus, a gentleman occupying a prominent public position, 
and in whom I had diagnosticated multiple cerebral sclero- 
sis mainly affecting the hemispheres, instead of making a 



284: DISEASES OF THE BRAIN. 

straight line with the pencil of the instrument, traced one 
of which the following cut is & facsimile • 

Fig. 8. 



Repeated efforts only gave worse results. 

In another case, that of a gentleman referred to me by 
my friend Dr. Yan Buren, the line made was as follows : 



Fig. 9. 



Here the patient was able to maintain the contraction at 
its original force for only about the sixth of a minute — the 
time required for the paper to traverse the pencil being 
exactly half a minute, and a third part of the line being 
horizontal. 

The ability to coordinate the affected muscles is always 
impaired, and thus in voluntary movements there is agita- 
tion independently of the esoteric tremor. This is seen not 
only in active movements but in passive muscular contrac- 
tions, such as those by which an article is held in the hand. 
In such a case the fingers cannot be kept in apposition with 
the object, but are moved about in a disorderly manner. 
The incoordination is manifestly connected with the inabil- 
ity to maintain a lengthened muscular contraction to which 
reference has just been made. 

Sometimes, by the strong effort of the will, assisted by 
the sense of sight, these last two difficulties may for a little 
while be overcome. A gentleman now under my charge, 
suffering from the affection in question, cannot, for instance, 



MULTIPLE CEREBRAL SCLEROSIS. 285 

carry a glass of water to his lips except by looking at it 
fixedly and concentrating all his •volitional power upon the 
act. His lower limbs are not yet affected, and he conse- 
quently can coordinate them, in walking and other move- 
ments, perfectly well. 

In another case, a lady, affected with multiple cerebral 
sclerosis, undertook to help her invalid husband to rise from 
his chair ; a band of music happening to pass the window, 
she turned to look at it, and, at once relaxing her hold, let 
him fall to the floor and injured him severely. 

Zenker 1 reports a case in which there was a similar loss 
of the appreciation of the state of the muscles; and another 
is mentioned by Reynolds, 2 under the head of " muscular 
anaesthesia." I am very sure that many cases of this last- 
named affection are instances of multiple cerebral sclero- 
sis of other ganglia, and I shall presently more specifically 
refer, under a different head, to two remarkable cases which 
have occurred in my own experience. 

Another phenomenon closely related with this incoordi- 
nation is generally present in multiple cerebral sclerosis, 
and that is, that the patient loses that innate or early- 
acquired knowledge of the exact situation of the several 
parts of his body. We can all of us, not thus affected, close 
our eyes, and touch, with the end of the finger, any particu- 
lar point on the face or rest of the body, with the utmost 
exactness. But a person with multiple cerebral sclerosis in- 
volving the hemispheres cannot do this. Thus, in attempt- 
ing, with the eyes shut, to place the end of the index-finger 
on the middle of the eyebrow, he misses that point, some- 
times by as much as two inches ; and, no matter how fre- 
quently he tries, he succeeds no better. It would appear 
that, in such cases, the normal instinct of topographical re- 
lation between the fingers and the cutaneous surface gen- 

1 Ein Beitrag zur Sklerose des Burns und Riickenmarks. Henle und Pfeu- 
fer's Zeitschrift fur Rationelle Medizin, Bd. xxiv., 1865. 
3 System of Medicine, vol. ii., p. 330. 



286 DISEASES OF THE BRAIN. 

erally, which all persons and many animals seem to possess, 
is impaired. 

The electro-muscular contractility is never, according to 
my experience, diminished in multiple cerebral sclerosis, un- 
complicated with similar lesions in the spinal cord. 

The attitude and gait of a person affected with multiple 
cerebral sclerosis are peculiar. In standing the body is gen- 
erally inclined forward, the head falling toward the chest, 
the trunk flexed at the pelvis, and the knees slightly bent. 
In walking the action is similar to a jog-trot, the body being 
still inclined forward, and the patient often moving with 
considerable rapidity. I have had several persons with the 
disease under my charge who could not walk at all, but who 
could run with surprising agility. One of these, a gentle- 
man advanced in life, sent to me by my friend Prof. Sayre, 
was unable to take a step in my consulting-room. He was 
carried down-stairs by his attendants with some difficulty, 
and when he reached the front-door he was put on his feet. 
He then told his servant to give him a push, which the man 
did with all his might, and the old gentleman, being started, 
went at a full run and jumped into his carriage without the 
least difficulty. 

There is often a strong tendency to plunge forward, and 
at times there is an impossibility of controlling it except by 
catching hold of some fixed object. ISTot long since I was 
walking down Broadway, when I saw in front of me a gen- 
tleman who was then under my charge, and in whom I had 
diagnosticated multiple cerebral sclerosis. Although aware 
of his peculiar impulsive gait, I had never seen it so strik- 
ingly manifested as it was then. He went at a full trot, 
threading his way among the numerous people in the street, 
until, apparently exhausted, he would lay hold of a lamp- 
post or awning-post and cling to it till he had recovered 
his breath, to start off again in a similar manner. 

This impulsion of the body forward makes it easy for the 
patient to ascend a staircase, but, on the contrary, very diffi- 



MULTIPLE CEREBRAL SCLEROSIS. 287 

cult to go down one. The first case cf the disease in question 
which I saw in this city, over six years ago, was character- 
ized by an extreme degree of festination. It was that of a 
maiden lady, over fifty years of age, who had been affected 
for several years. When she was going up-stairs no one 
could perceive the least irregularity in her gait, but to go 
down was impossible. 

Sometimes, however, the tendency is to go backward. 
This was the case, to a remarkable extent, in a gentleman, a 
resident of this city, who was sent to me by my friend Prof. 
Yan Buren. Every time he rose from his chair he was forced 
to take several steps backward, and it was only by constant 
mental effort that he was able to go forward at all. 

The tactile sensibility is generally impaired from a very 
early period in the course of the affection, and thus, the two 
points of the sssthesiometer must be more widely separated 
than in the normal condition of the system, in order to get 
two separate impressions. This anaesthesia bears no neces- 
sary relation to the region of skin covering the affected mus- 
cles. According to my experience, it is most marked at the 
terminal extremities of nerves. 

Numbness of different degrees, pains of various kinds, 
increased or diminished temperature, and excessive hyper- 
esthesia of the skin, may also exist. 

The special senses may be affected to a variable extent. 
Thus there may be amblyopia, or even complete blindness ; 
the taste is very often impaired or abolished, and the hear- 
ing rendered less acute. 

The ophthalmoscope should always be employed to ex- 
amine the fundus of the eye. The condition generally found 
to exist is white atrophy of the optic disk, which is identical 
in general features with sclerosis. The vessels of the retina 
will usually be found small, the branches of the veins few in 
number, and the choroid of a paler hue than is natural. 

The course of multiple cerebral sclerosis is progressive. 

The patient is finally unable to walk, the friction of his 



288 DISEASES OF THE BRAIN. 

shaking body against the bed abrades the skin, the dejections 
are passed involuntarily, and he dies either in coma, in con- 
vulsions, or by a gradual process of asthenia, his mind par- 
ticipating in the general decay. The duration of the disease 
varies from a few months to eight or ten years. Generally 
it runs its course in about fi.ve years. 

Causes. — Age is certainly one of the most powerful pre- 
disposing causes of multiple cerebral sclerosis mainly affect- 
ing the hemispheres, and causing the symptoms heretofore 
classed as paralysis agitans. Thus, of nine cases in which I 
diagnosticated the disease in question, all were over fifty 
years of age, and three were over sixty. I have seen numer- 
ous cases of paralytic tremor in younger persons, but the 
morbid condition had scarcely any points in common with 
that now under notice. Cases, however, are on record in 
which young persons were the subjects. There is some evi- 
dence to support the theory that it is sometimes hereditary, 
but the whole subject is so confused in the minds of most 
authors that it is difficult to make out clearly what they refer 
to under the designation of paralysis agitans. Of the nine 
cases occurring in my own practice, private and hospital, 
four had immediate ancestors who had suffered from some 
form of tremor and paralysis. Whether the lesion was 
purely cerebral, cerebro-spinal, or whether the disease was 
entirely functional, I was not able to decide from the infor- 
mation given. 

The influence of sex is more readily ascertained and is very 
evident. Seven of my cases were males and only two females. 

Of exciting causes there are many. In two of my cases 
it followed immediately on attacks of scarlet fever, in one 
it was a sequence of typhoid fever, in one it ensued after 
rheumatism, in one it was probably syphilitic, in two it was 
apparently excited by great emotional disturbance, in one 
by inordinate muscular exertion, and in two no cause could 
be assigned, or at least there was not, in my opinion, any 
sufficient exciting cause to be discovered. 



MULTIPLE CEREBRAL SCLEROSIS. 289 

Diagnosis. — Multiple cerebral sclerosis has heretofore been 
confounded with other diseases, and its very existence as an 
independent affection is doubted by my friend Dr. M. Cly- 
mer, 1 and other writers. To this point I will return when 
the morbid anatomy and pathology are discussed, and, as 
in the foregoing account of the symptoms and causes, will 
base my remarks under the present head mainly on the re- 
sults of my own experience. 

The occurrence of " head-symptoms " is sufficient to di- 
agnosticate multiple cerebral sclerosis from the functional 
paralysis agitans, which is never a very serious affection, and 
the seat of which is not centric. Besides, in the latter there 
are no festination, alterations of sensibility, incoordination, 
muscular anaesthesia, or inability to maintain a continuous 
muscular contraction, while the paper of the dynaomgraph 
traverses the pencil of the instrument. The functional dis- 
order is more liable to occur in persons under fifty than in 
those over that age. From the cerebro-spinal form of mul- 
tiple sclerosis, which will be fully considered in another sec- 
tion of this work, it is distinguished mainly by the facts 
that the tremor makes its appearance before the paralysis, 
and that the agitation is present whether voluntary move- 
ments are being made or not. 

"With the purely spinal form it is not likely to be con- 
founded by any one paying the slightest attention to the 
phenomena of the two diseases. 

From chorea it might in some cases not be readily dis- 
criminated without a thorough study ot the clinical history 
and existing symptoms. But, though chorea sometimes 
occurs in adults, and is generally accompanied by " head- 
symptoms," the two affections possess few other phenomena 
in common. 

In the first place, the mental symptoms in chorea are in- 
dicative of feebleness from the very first, while in multiple 

1 Notes on the Physiology and Pathology of the Nervous System, with refer- 
ence to Clinical Medicine, New York, lS^O, p. 11. 
19 



290 DISEASES OF THE BRAIN. 

cerebral sclerosis imbecility supervenes late in the course of 
the disorder. In chorea there are no vertigo, pain in the 
head, or other evidences of congestion, while in the disease 
under notice these are among the very earliest symptoms. 
In chorea there is no actual tremor, but the disorderly 
movements are more extensive and irregular than in multi- 
ple cerebral sclerosis ; neither is there festination or bending 
of the body forward. 

Tremor is sometimes met with after cerebral haemor- 
rhage or other cause producing hemiplegia, but in such 
cases the clinical history, and the fact that the trembling 
comes on after the paralysis, will suffice to render the diag- 
nosis sure. 

Prognosis. — The prospect of recovery is always unfavor- 
able, but not, I am induced to think, absolutely hopeless if 
the patient be seen sufficiently early in the course of the 
disease and submitted to proper medical treatment. The 
probability of an arrest of the onward tendency is by no 
means small under like circumstances. Still, in the great 
majority of cases, all means fail, and the affection gradually 
and persistently goes on to its termination, death. 

Morbid Anatomy. — The membranes of the brain are some- 
times opaque in patches and occasionally contain an abnor- 
mal amount of serous fluid. The cerebral convolutions are 
occasionally flattened, and the gray substance is thinner than 
in the normal condition. It may also be changed in color, 
being pale, and scarcely, according to Jaccoud, to be distin- 
guished from the white substance. 

On cutting into the -tissue of the hemispheres, plates or 
nodules of hardened matter are found scattered throughout 
its extent. These are well defined and vary in size from 
that of a cherry-stone to that of a small walnut. In the 
only case in which I have had the opportunity of making a 
post-mortem examination, they were confined entirely to the 
white substance of the hemispheres. Their color is white 
or grayish- white, and they are of varying degrees of consist- 



MULTIPLE CEREBRAL SCLEROSIS.. 291 

ency from that of hard-boiled white of egg to that of car- 
tilage. 

Examined with the microscope, they are seen to consist 
of the neuroglia, which, to a great extent, has taken the 
place of the nervous tissue, and of the debris of this latter in 
the forms of fibres, nucleated cells, and free nuclei. They 
are formed, therefore, by the hypertrophy of the connective 
tissue of the brain at the expense of the nervous tissue 
proper. 

Sometimes there are very few of these deposits — indeed, 
there may only be one — and at others they are present in 
large numbers. In the case examined by myself there were 
seven in the left hemisphere and eleven in the right, of sizes 
varying as previously stated. 

They may be found in other parts of the cerebral mass 
besides the hemispheres, though in the form under con- 
sideration these are their most prominent and constant 
seats. Thus, they may exist in the hemispheres and in 
the medulla oblongata, the pons Varolii, and the cere- 
bellum, at the same time. When they occupy, likewise, 
the spinal cord, another disease is produced which differs 
anatomically and pathologically from multiple cerebral 
sclerosis. 

Sometimes large numbers of amyloid corpuscles are met 
with, but their presence is not constant. 

Pathology. — The first question to be considered under 
this head relates to the existence of multiple cerebral scle- 
rosis as an independent affection — that is, without lesions of 
like character being at the same time produced in the spinal 
cord. 

The weight of authority is probably against the view 
expressed in this chapter, and, as I have, so far as I know, 
made the first attempt to identify a certain group of symp- 
toms with multiple sclerosis limited to the cerebral ganglia, 
I am the more desirous to place the reasons by which I have 
been actuated before the reader. 



292 DISEASES OF THE BRAIN. 

Andral, 1 under the designation of partial induration of 
the brain, describes the morbid anatomy of an affection 
which is probably the same as that under present considera- 
tion, although his account of it is by no means full or pre- 
cise. 

Yalentiner, 2 citing a number of cases observed by him- 
self and Frerichs, details one in which the lesions were lim- 
ited to the brain, and in which the symptoms were similar 
to those I have specified in this chapter. 

Jaccoud declares that certain cases establish the possi- 
bility of sclerosis limited to the encephalon. In a note he 
refers to several writers who have stated the parts affected, 
in some of which, however, the spinal cord was also involved. 
In the following it appears to have been restricted to the 
brain : 

Stoehr, hemispheres corpora mamillaria ; Dumville, pro- 
tuberance medulla oblongata and corpora olivaria; Pool, 
hemispheres centrum ovale; Cruveilhier, anterior face of 
the medulla oblongata, protuberance, cerebral peduncles, 
corpus callosum, walls of the lateral ventricles, and the ori- 
gins of the pneumogastric glossopharyngeal and hypoglossal 
nerves ; Duplay, hemispheres, particularly in the vicinity of 
the ventricles, optic thalami, and corpora striata; Van 
Camp, protuberance ; Obertimpfler, hemispheres ; Barthez 
and Rilliet, hemispheres, particularly one convolution ; Cohn, 
hemispheres in two cases ; Gunsburg, hemisphere, gray sub- 
stance of the convolutions ; Valentiner-Frerichs, cerebellar 
peduncles, corpora olivaria, protuberance, and medulla ob- 
longata ; Meynert, cerebellum and protuberance. 3 

Bourne ville and Guerard, 4 while asserting that the exist- 

1 Preces d'Anatomie Pathologique, tome ii., 2 e Partie, Paris, 1829, p. 810. 

2 Uber die Sklerose des Gehirns und Riickenmarks. Deutsche Klinic, B. 
xiv., 1856. 

3 I quote this note from Jaccoud, without vouching for its correctness, as, 
from the fact that he does not cite the works in which the details are to be 
found, I have not been able to verify his statements. 

4 De la Sclerose en Plaques Disseminees, Paris, 1869. Analyzed by Dr. E. 



MULTIPLE CEREBRAL SCLEROSIS. 293 

ence of multiple cerebral sclerosis as a separate and distinct 
affection rests on only one case — that of Yalentiner — which 
they further declare was probably imperfectly reported, ad- 
mit that the cerebral form may be regarded as established. 
But none of the authors who have referred to it identify a 
form of paralysis agitans with a lesion characterized by the 
presence of bodies of sclerosed tissue in the brain, and espe- 
cially in the hemispheres. Thus, Dr. Clymer expresses the 
opinion that, excluding the tremor, which may accompany 
hemiplegia and certain other disorders of which it is an alto- 
gether secondary phenomenon, there are but two varieties of 
paralysis agitans : 1. That which results from multiple (dis- 
seminated) sclerosis, affecting the encephalon and spinal cord ; 
and, 2. A purely functional disorder, first fully described by 
Parkinson. 1 Now, in my opinion, Parkinson has described 
two very distinct affections under the name of paralysis agi- 
tans. One of these is certainly functional so far as this ; that 
the tremor shows no disposition to extend to distant parts of 
the body, that it is the only symptom present, that no lesion 
has been discovered, and that it is readily cured ; the other 
is characterized by the phenomena which I have detailed in 
this chapter, and which, though imperfectly described by 
other authors, have either been confounded with multiple 
cerebro-spinal sclerosis, or regarded as constituting an ag- 
gravated form of the functional disorder. My views of its 
true pathology have been formed from careful observation 
of the course of the disease in nine cases, in one of which 
I was enabled to make a post-mortem examination. 

P. B., male, aged sixty-five, formerly a drummer in the 
army, and latterly an instructor of buglers, came under my 
observation at Ceboleta, New Mexico, in the winter of 1849- 

C. Seguin in Archives de Physiologie, etc. No. 4, Juillet et Aout, 18*70, p. 524, 
et seq. 

1 Essay on the Shaking-Palsy, London, 1817. I have not been able to find a 
copy of this work in New York, and have for several years been unsuccessfully 
trying to obtain it. My citations from it are therefore second-hand. 



294: DISEASES OF THE BRAIN. 

'50. "While milking a cow, one evening, he suddenly ex 
perienced a severe pain in his head, which lasted only a few 
seconds. He soon afterward had an epileptic paroxysm, 
during which he bit his tongue severely. He had no other 
fit, so far as was known, but the pain in the head recurred 
at different times, never, however, lasting longer than a min- 
ute or two. 

No other symptom appeared for several weeks, and then 
he experienced severe darting pains in the arms, and soon 
afterward the left hand began to shake. On examination I 
found the tremor limited entirely to the extensor communis 
digitorum, and that the motion was entirely in the line of 
extension and flexion. Little by little the other muscles of 
the forearm became involved, and then the disorder extend- 
ed upward, affecting the biceps coraco-brachialis triceps, del- 
toid, and the muscles of the shoulder generally. The arm 
was much weaker than the other, although he was left- 
handed. 

In about three months after first noticing the tremor in 
the left hand, the left foot began to shake, and, as in the first 
instance, the agitation gradually extended upward, until, so 
far as I could see, all the muscles of the extremity were in- 
volved. 

He now complained of numbness in the ends of the 
fingers of the affected extremity, and this slowly ex- 
tended to the whole arm. The sensibility of the leg re- 
mained intact. 

Next the right arm went through a similar sequence of 
phenomena, then the right leg, and finally the head. 

There was no decided tendency to forward impulsion till 
both legs were involved, though there was difficulty in main- 
taining the erect posture, and the body was inclined forward 
before either inferior extremity became affected. But, with 
the accession of tremor in both lower limbs, a marked dispo- 
sition to trot and a corresponding difficulty of walking 
slowly made their appearance. 



MULTIPLE CEREBRAL SCLEROSIS. 295 

For over a year the tremor ceased as soon as the patient 
went to sleep, and it generally became less troublesome as 
soon as he lay down and tried to sleep. But at last it con- 
tinued night and day, and thus apparently hastened the ter- 
mination of the disease, for he lost strength rapidly from de- 
privation of sleep. This debility was still further increased 
by innutrition from improper food, it being impossible, 
in the then state of the country, to get any fresh vege- 
tables. 

During the whole period from the occurrence of the first 
paroxysm of pain, there was a gradual but marked failure 
of the mental powers, until a condition of very decided 
imbecility was reached. Death finally took place about 
two years and one month after the epileptic fit, which 
occurred on the same day with the first pain felt in the 
head. 

I made the post-mortem examination with great care, 
but without any clearly-preconceived idea of what I should 
find, except that I expected to discover lesions of some kind 
in the brain and spinal cord. On removing the calvarium, 
the membranes covering the surface of the hemispheres were 
found to be healthy. I removed the entire brain from the 
skull, and carefully examined the base. There was no ap- 
preciable lesion of any kind. ]STo tumor, no induration, no 
softening of any of the ganglia. The membranes were dis- 
sected off, and the convolutions on the superior surface were, 
I thought, less distinctly marked than was normal. I then 
cut through the right hemisphere horizontally an inch from 
the surface, and was surprised to find the course of the scal- 
pel resisted by a hard body. This I discovered to be a mass 
of dense tissue one inch and a quarter long, half an inch 
wide, and about half an inch thick. I then very thoroughly 
examined the hemisphere, not allowing any part of it 
to escape observation, and discovered eleven of these no- 
dules of variable size — the smallest as large as a cherry- 
stone, the largest about the size of a walnut — in the white 



296 DISEASES OF THE BRAIN. 

substance. In the left hemisphere I found seven similar 
masses. 

There were none in the peduncles, in the optic thalami, 
in the corpora striata, in the medulla oblongata, pons Yarolii, 
cerebellum, or any other part of the encephalic mass. 

I then examined the spinal cord in like manner, making 
several hundred sections of it, but found no alteration any- 
where. It was perfectly healthy in every respect, neither 
congested, softened, nor indurated in any part of its ex- 
tent. 

The sclerosed bodies were, many of them, dense and as 
hard as cartilage, others were like hard-boiled white of egg, 
and others like cheese. ~No microscopical examination was 
made. 

In this case the lesions were entirely limited to the hemi- 
spheres, a circumstance which I can well believe is not com- 
mon — other ganglia of the brain generally participating 
and giving rise to corresponding modifications of, or addi- 
tions to, the symptoms. 

Thus, when the medulla oblongata is involved, there is 
difficulty of swallowing and implication of the muscles of 
respiration ; when the pons Yarolii is affected, we have among 
other symptoms facial paralysis ; when the corpora striata, 
more intense paralysis ; when the optic thalami, derangement 
of vision and perhaps of hearing ; when the crura cerebri, 
various unilateral convulsive movements and participation 
of the muscles supplied by the third pair of nerves ; and 
when the cerebellum, especially the crura, the tendency to 
go backward instead of forward ; and so on with the other 
important parts of the encephalic mass. 

Other relations connected with the pathology will be 
considered when the subjects of multiple cerebro-spinal scle- 
rosis, and what, for want of a better name, may be called 
paralysis agitans, are reached. 

Treatment. — To detail all the various methods which 
have been employed in the treatment of the group of symp- 



MULTIPLE CEREBRAL SCLEROSIS. 297 

toms which I have clawed together as multiple cerebral 
sclerosis mainly affecting the hemispheres, would be a fruit- 
less piece of labor. Many of the cases of cure which have 
been reported were not instances of the disease now under 
notice, but of the milder, and, so far as we know, functional 
disorder ; and, therefore, it would be useless to adduce them 
as guides in the present connection. I shall therefore con- 
fine my remarks to the results of my own experience. 

I am very sure that the condition of the patient is gen- 
erally improved by the simultaneous administration of the 
chloride of barium and hyoscyamus. The former may be 
employed according to the formula given in the immediately 
preceding chapter ; that is, in doses of a grain three times 
a day ; the other in the form of the tincture, in doses of 
from one to two drachms morning, noon, and night. Care 
should be taken that the latter preparation be fresh and 
properly made. As sold in the apothecaries' shops, it is 
often inert. , 

By these two remedies alone, the tremor is often mark- 
edly diminished, and the paralysis and other disorders of 
motility and sensibility greatly lessened. 

Thus, in the case of a distinguished gentleman, a Sena- 
tor of the United States, who consulted me in the spring 
of 1870 for what was designated shaking-palsy, but in whom 
I diagnosticated the disease under consideration, amendment 
was perceived from the very first day of the treatment. 
The tremor and paralysis diminished, the mind became 
stronger and more able to endure exertion, and the physical 
strength much increased. He was soon able to write and 
to attend to his official duties, and he has continued in his 
advanced stage of improvement to the present date. He 
still, however, takes his medicines, and will probably be 
obliged to do so for a long time yet. 

In another case — that of a gentleman living in the in- 
terior of this State — no means have been so successful in 
improving the general health, and arresting the progress of 



298 DISEASES OF THE BRAIN. 

the disease, as the chloride of barium and tincture of hyos- 
cyamus. I have given these remedies alone or in conjunc- 
tion with others in six cases, and never without a decidedly 
favorable effect. 

Electricity is, however, a powerful adjunct, and I always 
employ it when the opportunity exists for so doing. The 
primary current, from fifteen of Smee's cells, should be 
passed through the brain antero-posteriorly and laterally, 
as previously described, and the sympathetic nerve should 
likewise be acted upon by a current of similar intensity. 

The tremulous muscles should also be subjected to the 
influence of a primary current of low tension. I am not 
sure that it makes any difference in which direction the 
current be passed, but it is important that it should not be 
so intense as to cause any considerable pain. 

For the paralysis the induced current — not too strong — 
is to be recommended, and for any contractions that may 
be present it is the preferable form to use. 

A gentleman, over sixty years of age, from Tennessee, 
consulted me in September, 1870, for tremor associated 
with paralysis. His physician, Dr. W. "W. Yandell, came 
with him, and gave me much valuable information in regard 
to the progress of the disease. In the first place, there had 
been, several years previously, symptoms of a disordered 
cerebral circulation, indicated by pain and vertigo. Soon 
afterward tremor supervened in the left hand, and gradually 
extended to both limbs of that side. There were also paraly- 
sis and loss of sensibility. When he came under my notice, 
the upper extremity was more affected than the lower ; con- 
tractions had taken place, and the fingers were strongly 
pressed against the palm of the hand, the hand was bent on 
the forarm, and the elbow was flexed to its utmost extent. 
The limb was somewhat atrophied, but electro-muscular 
contractility was not sensibly impaired. 

The voice was exceedingly weak, but there was no paraly- 
sis of the tongue or facial muscles, and, though the patient 



MULTIPLE CEREBRAL SCLEROSIS. 

could not speak above a whisper, every word was articulated 
distinctly, and was appropriately used. The body was greatly 
bent forward, the attitude being that of a person ascending 
a steep hill, and there was decided festination. The tremor 
and paralysis were much more marked on the left side than 
the right, and the agitation was altogether independent of 
voluntary movements. 

The mind, except as regarded the memory, was not essen- 
tially impaired, and the sight and hearing were unaffected 
by the disease. There had never been any convulsive at- 
tack or loss of consciousness, and the course of the disease 
had been extremely gradual. Ophthalmoscopic examina- 
tion revealed nothing beyond an anaemic condition of the 
retinae and choroids. 

I diagnosticated multiple cerebral sclerosis mainly affect- 
ing the hemispheres, but probably involving also the right 
corpus striatum, and I prescribed the chloride of barium, 
tincture of hyoscyamus, and electricity. He remained in 
New York a few days, and then returned to his home with 
the tremor abated, the contractions partially overcome, the 
muscles improved in strength, and the tendency to festina- 
tion lessened. 

A month afterward Dr. Yandell, who had continued the 
treatment, wrote me, of the patient, that the improvement 
was more decided than his most sanguine friends had anti- 
cipated, and still continued ; that the agitation was scarcely 
perceptible ; that he could more than half extend the fingers 
of the left hand, could straighten the wrist and elbow, and 
could lift a chair, or put on his hat, with the right hand. 
From what I have since ascertained, he bids fair to recover 
entirely. 

If the general health be materially impaired, cod-liver 
oil, iron, and strychnia, may be administered with advan- 
tage. 

The food should always be highly nutritious, and a glass 
or two of wine, if not particularly contraindicated, may be 



300 DISEASES OF THE BRAIN. 

taken daily with advantage. Passive exercise in the open 
air is always beneficial, but excessive walking or strong 
muscular exertion of any kind should be carefully avoided. 
Emotional excitement or mental labor must be rigidly 
avoided. 

Under the treatment thus indicated, the patient may at 
least be relieved of a great deal of his suffering. 



CHAPTER XIY. 

TUMOBS OF THE BRAIN. 

Though tumors of the brain differ greatly in charac- 
ter, they all, when they are accompanied by any notable 
symptoms, present many features in common. It will, 
therefore, be convenient to consider them under one head, 
and point out their differences when the morbid anatomy 
and pathology are discussed. 

Symptoms. — It is possible for a person to have a tumor of 
the brain as large as an orange, and present no symptoms 
of it during life. One such case came under my observation 
several years ago, and many others are on record. In the 
instance referred to, the patient, a teamster, was twice shot 
in a quarrel, one ball grazed the skull, ploughing up the 
right parietal bone for the extent of an inch ; the other 
entered the left breast, wounding the heart. Death ensued 
almost instantly. The brain was examined, and a tumor of 
an elliptical form, two inches in its long diameter, and one 
and three-quarters in its short diameter, was found, involv- 
ing the white substance of the left posterior lobe. The char- 
acter was that which Yirchow has since called gliomatous, 
and contained no nervous tissue. 

Again, it sometimes happens that tumors of large size 
exist in the brain, and produce no symptoms till a few days 
before death. Then very violent manifestations ensue, and 
the patient dies convulsed or comatose. And it is always 
the case that the symptoms are entirely different, as one or 
other part of the brain is involved, or the tumor is large or 



302 DISEASES OF THE BRAIN. 

small. Thus, we know very well that a morbid growth, 
seated in the pons Yarolii, will cause very diverse symptoms 
from those produced by a similar formation in one of the 
anterior lobes of the hemispheres. "We may say, in general 
terms, that tumors situated in the medulla oblongata, the 
pons, the optic thalami, the corpora striata, the crura cere- 
bri, the cerebellum, and the convex surface of the hemi- 
spheres, give rise to more decided manifestations than when 
the white substance of the hemispheres is the seat. 

Pain is probably the first symptom which attracts atten- 
tion. It is generally confined to a definite region of the 
head corresponding to the location of the disease, but this is 
not always the case. It may be either a dull ache, lasting 
the greater portion of the day, or a sharp, lancinating par- 
oxysm, which ensues but for a few moments and recurs 
frequently. As the morbid process goes on, the cephalalgia 
becomes more severe, and finally reaches a stage of great in- 
tensity. So great is the suffering that the patient cries out 
with the agony, and in a case under my observation suicide 
was attempted. Mental excitement, physical exertion, 
noises, and bright lights, aggravate the pain. 

The special senses rarely escape. The sight is among 
the first to suffer derangement, and vision may be irretriev- 
ably lost from pressure exerted upon the optic nerve, or 
through congestion of the retina and choroid and consequent 
disorganization of these structures. The eyeball of the af- 
fected side is often rendered more prominent than the other, 
even when the tumor does not involve the orbit. 

The hearing is also often affected, and the taste not un- 
frequently perverted or lessened in acuteness. 

Disorders of sensibility in various parts of the body are 
common. Tliese are either of the nature of anaesthesia or 
hyperesthesia, and are usually experienced in the face or 
extremities. 

Vertigo is a very general symptom, and may be of all 
degrees of intensity, sometimes preventing the patient stand- 



TUMORS OF THE BRAIN. 303 

ing, walking, or even sitting. It is often observed very 
early in the course of the disease, and is frequently accom- 
panied by nausea or vomiting. 

The disorders of motility are shown either as paralysis or 
convulsions. In several cases under my observation the loss 
of muscular power was first exhibited in the muscles of the 
eyeball and its appendages, causing external strabismus, 
ptosis, and permanent dilatation of the pupil, from paraly- 
sis of the third nerve, or internal strabismus from the lesion 
involving the sixth nerve. 

In a case now under my charge, the muscles supplied by 
the right facial nerve are alone affected, and in another 
the left side of the face and right side of the body are para- 
lyzed. "When there is paralysis, it is generally of the hemi- 
plegic form, though occasionally it is paraplegic. Whatever 
its form, it is almost always of slow progress. Paralysis 
may be entirely absent. It is only a necessary attendant 
when the tumor involves some part of the motor tract. 

When the muscles concerned in articulation are impli- 
cated, the speech is rendered indistinct, and some sounds 
may be impossible of utterance, not from any defect in the 
idea of language or of its expression, but simply from pare- 
sis of the vocal organs. 

Convulsions are other prominent symptoms, and they 
may be among the initial phenomena. It is not at all un- 
usual for the first evidence of intra-cranial disturbance to be 
an epileptiform convulsion, and similar paroxysms may oc- 
cur at intervals for many years. They may be general, or, 
what is more common, limited to one side of the body. 

Sometimes consciousness is not lost, but there are various 
convulsive movements of the limbs, tonic or clonic in char- 
acter. Occasionally these are confined to the muscles of the 
face or eyeball. 

Disturbances of equilibrium, manifested by tendency to 
advance, to go backward, or to turn round to the right or 
left, are sometimes present. 



304 DISEASES OF THE BRAIN. 

With these symptoms there are generally others not so 
palpably connected with the morbid intra-cranial process. 
Thus there may be disorders of the stomach, bowels, and 
kidneys, and of the respiration and circulation, which add 
much to the discomfort of the patient. 

As to the intellectual faculties, it is not uncommon to 
find that they do not become involved to any considerable 
extent till a late period of the disease. Then the change is 
usually a gradually-advancing imbecility. 

Death takes place either by convulsions or coma, or a 
combination of both. The following cases, which I select 
from my note-book, are interesting in several relations : 

J. EL, male, aged thirty-seven, came under my obser- 
vation January 15, 1856, at Fort Riley, in Kansas. A 
few months before he had received an injury of the left hip 
by being thrown from his horse, and was stunned for a few 
minutes. A few days afterward, as he was lying in bed, he 
suddenly became vertiginous, and at the same time had 
noises in his ears and some pain not very definitely located. 
He never had vertigo again, but the pain never left him 
night or day for several weeks. It then suddenly ceased, 
and did not recur till the morning of December 31st, when a 
sharp twinge was experienced in the front of the head, and 
he immediately saw every thing double. Ptosis and dilated 
pupil of the left eye soon supervened, and the arm of the 
right side became weaker. When I saw him the grasp of 
his hand was very feeble, and the ocular troubles very 
noticeable. The pain was almost constantly present, and 
was of the most intense character. He said it seemed as if 
a red-hot iron were being thrust through his brain. 

He had come several miles to see me, and went home 
after I had given him a palliative medicine. A few days 
afterward a messenger came for me in great haste, with the 
information that the patient was dying, and requesting my 
attendance. On my arrival, I found that he had been dead 
several hours, having had repeated severe convulsions. On 



TUMORS OF THE BRAIN. 305 

post-inortem examination, a tumor, spheroidal in shape, with 
an average diameter of an inch and a quarter, was found 
occupying the middle third of the inner surface of the left 
middle lobe, so as to press on the left crus and third nerve. 

The points of interest in this case are the sudden cessa- 
tion of the pain and its recurrence simultaneously with the 
paralysis of the third nerve, the slight paralysis of the body, 
and the absence of convulsions till just before the fatal ter- 
mination. The ptosis, diplopia, and dilatation of the pupil, 
doubtless occurred at the very instant that the tumor en- 
croached on the crus. 

The history of the following case, which I saw in Sep- 
tember, 1864, at the request of my friend Prof. Yan Buren, 
I take from the report of Dr. F. 1ST. Otis, 1 under whose 
immediate care the patient was : 

Miss E., aged twenty-six, was of healthy parentage, and, 
though of delicate organization, had enjoyed good health up 
to February, 1861, when she received a fall on the ice, strik- 
ing violently upon her elbow. She was not conscious of re- 
ceiving any other injury at the time. At three a. m. of the 
following day she awoke with an intense pain in the top of 
her head, of a throbbing, lancinating character, which con- 
tinued throughout the day. By night she obtained relief. 
No further effect from the fall was experienced until about 
two weeks subsequently, when she discovered a small firm 
circumscribed swelling on the crown of the head at the point 
where the pain had previously been felt. This swelling, 
which was painless, increased gradually, until, after a year, 
it had attained the size of half a lemon. Soon after the ap- 
pearance of the tumor, Miss E. began to suffer with severe 
pain, confined chiefly to the vertex, of the same character as 
that experienced immediately after the fall. This pain 
would continue almost without cessation for two or three 
weeks, after which for a like period she would be quite free 
from it. 

1 New York Medical Journal, vol. i., 1865, p. 26. 
20 



306 DISEASES OF THE BRAIN. 

She had also occasional attacks of numbness, preceded by 
great drowsiness, and a cold, creeping sensation, succeeded 
by total loss of the power of motion, sometimes confined to 
a single extremity, and at others involving the entire body. 
These attacks usually came on at night, or after rest in a re- 
cumbent position, and generally, though not invariably, 
were precursors of severe headache. They were always fol- 
lowed by great nervous prostration. At first rare, they in- 
creased in frequency as the tumor enlarged, so that by Feb- 
ruary, 1863, she was seldom free from them for more than 
ten or twelve days, and the tumor had doubled in size within 
the year. She now began to be much annoyed by tingling, 
crawling sensations in her face and through the head after 
any unusual exertion in writing, reading, or singing, but 
rode daily on horseback with apparent benefit. As time 
passed, she had frequent dizzy turns, with nausea, and sud- 
den flashes like electric shocks passing over the entire 
body, lasting only for an instant, but leaving her much 
prostrated. The headache, which was always of the most 
agonizing description, came to be referred chiefly to the, 
tumor, though often associated with pain through the tem- 
ples and other parts of the head. The muscles of the neck 
sometimes became rigid, and the vision, as well as the sense 
of taste and smell, often became very imperfect and con- 
tinued so for weeks. Sometimes the power of speech would 
be lost, but she always retained perfect consciousness. These 
attacks rarely lasted more than an hour or two. 

On the 23d of October, 1864, she was attacked with a 
peritoneal inflammation, from the effects of which she died 
on the ninth day thereafter. Leaving out the details of the 
post-mortem examination of other parts of the body, we find 
that an incision was made across the vertex from ear to 
ear, and the skin dissected from the tumor, at the apex of 
which it was found to be firmly adherent. The calvarium 
was then sawn in a line one inch above the orbital margin 
around to the occipital protuberance; the hemispheres of 



TUMORS OF THE BRAIN. 



307 



the cerebrum were then sliced, and the whole raised at the 
same time. 

On removing the two hemispheres, which were adhe- 
rent above, a tumor one and a quarter inch in thickness and 
three inches in diameter, of a dull lemon-yellow color, a 
little softer than the cerebral substance, and separated into 
two lateral halves, was seen springing from the central sur- 
face of the dura mater. This intra-cranial tumor had insin- 
uated itself into the sulci between the convolutions, and the 
dura mater could be traced between it and the bones. The 
situation of the tumor, and the relation to the exterior 
growth, are shown in the accompanying cut : 

Fig. 10. 




The microscopical examination by Dr. Gouley gave indi- 
cations that both formations were encephaloid in character. 

Similar cases to the foregoing have been reported by 
Mr. Paget, 1 of London, and by the late Dr. Isaacs, 2 of this 

1 Surgical Pathology, London, 1853, vol. ii., p. 221. 

2 Transactions of the Medical Society of the State of New York, 1859. 



308 DISEASES OF THE BRAIN. 

city. It will be noticed that, in the case just cited, there 
were neither convulsions, paralysis, ansesthesia, mental de- 
rangement, nor difficulties of speech. When I saw the young 
lady, not long before her death, there were no symptoms 
present from which it could have been inferred that a tu- 
mor occupied any part of the intra-cranial cavity. 

I. K., a general officer of volunteers during the late war, 
consulted me in the spring of 1870, through his brother, for 
what was thought to be softening of the brain. The patient 
was stout and well made, had no difficulty of speech, no de- 
rangement of sensibility, and no paralysis of any part of the 
body. His senses were remarkably acute. His memory, 
however, was almost entirely gone, he had forgotten the 
names of his children, did not even know what city he was 
in, and could not tell me where he had been just before 
coming to see me. Besides this there was absolutely noth- 
ing. His strength was enormous, and his grip one that I 
shall not readily forget. 

His previous history was that he had served arduously 
through the war, and had, on being mustered out of service, 
resumed his business as a lumber-merchant. No syphilitic 
taint could be discovered. Six months before I saw him ho 
had been suddenly seized with an epileptiform paroxysm, 
which was followed by agonizing pain in the head. A 
second convulsion ensued in about a month afterward, the 
pain continuing to be of the utmost severity, and almost 
without intermission. There was a third attack, and then 
the pain ceased; but the failure of memory began to be 
manifested from that moment, and had gradually been be- 
coming more pronounced. 

I diagnosticated a tumor involving mainly the white 
substance of one of the hemispheres, situated probably in 
the posterior lobe, and not affecting the motor tract, or the 
course of any of the cranial nerves. My principal reasons 
for not regarding the lesion as softening were the absence 
of paralysis or even paresis, the integrity of all the special 



TUMORS OF THE BRAIN. 309 

senses, and the absolute perfection of articulation. At the 
same time I regarded the matter as extremely doubtful, and 
I cite the case here merely as one of interest in which the 
difficulty was probably a tumor. The patient died during 
the first week in January of the present year (1871), but I 
have received no details of any post-mortem examination. 

In May, 1870, I was requested by Dr. Hermann Knapp 
to meet him in consultation in the case of a gentleman suf- 
fering from a cerebral tumor. The morbid growth appar- 
ently occupied the right anterior lobe of the brain, and in- 
volved also the temporal region of the skull on the same 
side. The sight of the right eye was destroyed, and that of 
the left so much impaired that only strong lights or shadows 
could be distinguished. The lymphatic glands of the neck 
were very much enlarged. 

The pain was most acute night and day, with scarcely 
an intermission. The right arm was numb and paralytic, 
but there was no absolute paralysis anywhere except in the 
ocular muscles. The mind was intact, and there had never 
been a convulsion. 

Under the use of the iodide of potassium and the protio- 
dide of mercury the swelling of the cranium diminished, 
the swollen lymphatic glands were reduced, and the pain 
almost entirely abolished. I saw him several times after- 
ward, and, when I discontinued my visits, he was doing 
wonderfully well. Since then I have lost sight of him. 

There was no history of syphilis in this case. 

The following account of a case, in which there was a 
tumor of the cerebellum, I have from my friend Prof. Aus- 
tin Flint, M. D. : 

"In June, 1842, I was present, by invitation of Dr. 
James P. White, of Buffalo, at the autopsy in the case of 
"W. E., aged about forty years. I noted at that time the 
following brief account of the history as stated by Dr. 
"White the attending physician : 

" The illness was dated from the preceding February 



310 DISEASES OF THE BRAIN. 

(five months), but he had previously complained of pain in 
the head, and lassitude. In February he had had chills, 
which were at first attributed to malaria. Subsequently 
vomiting was a prominent symptom; it occurred in the 
morning immediately after rising from bed. Cephalalgia 
was a frequent, not a constant, symptom. He referred the 
pain especially to the occiput. In April he left Buffalo to 
visit friends in Rochester. He was prostrated by the jour- 
ney, and, his condition now being alarming, he returned 
home. Notwithstanding the treatment adopted, he gradu- 
ally failed, and died June 7th. 

" There had never been convulsions nor paralysis. 

"Post-mortem Examination. — The body was consider- 
ably emaciated. There was slight opacity of the arachnoid, 
and in some situations a small quantity of serum was effused 
beneath this membrane. The effusion within the ventricles 
was somewhat greater than usual. With these exceptions 
there were no morbid appearances, except in the cerebellum. 
Here was a tumor of the size of an English walnut. It 
was of fine consistence, and supposed to be tuberculous. 
There was no appearance of inflammation or softening of the 
cerebral substance around the tumor, which was situated in 
the right lobe of the cerebellum. 

" It was ascertained in this case that the venereal appe- 
tite had been wanting for many months before death. I 
recollect that Dr. White informed me at the time that ver- 
tigo was a feature in this case, and that it induced unsteadi- 
ness in the voluntary movements. Dr. White has since in- 
formed me that his recollection is now distinct as regards 
this point." 

A very important paper on intra-cranial tumors is that 
of my friend Prof. Roberts Bartholow, M. D., 1 of Cincinnati. 
Dr. Bartholow has discussed the relations of symptoms to 
lesions with great perspicuity and fulness. 

1 Report on Intra-cranial Tumors ; their Symptomatology and Diagnosis, 
with Illustrated Cases, Columbus, 1869. 



TUMORS OF THE BRAIN. 311 

This able observer divides the symptoms produced by 
cerebral tumors into two orders : 

1. Those common to morbid growths or adventitious 
products in general. 

2. Those peculiar to tumors in special situations. 

In the first order are to be placed headache, vertigo, am- 
aurosis, convulsions, and derangement of the intellectual 
and reflective faculties ; in the second alterations of sensibili- 
ty, disturbances of the special senses, disorders of motility, 
vomiting, and urinary disorders. 

Causes. — The causes of cerebral tumors are so intimately 
connected with their character that a classification becomes 
at once necessary. Following Jaccoud 1 in this respect, I 
shall divide them into four groups : the vascular, the par- 
asitic, the diathetic or constitutional, and the accidental. 
Even with this division we shall find that our knowledge of 
their etiology is not extensive. 

Vascular tumors are aneurisms of the cerebral arteries. 
The term does not include the capillary aneurisms of Bour- 
chard and Charcot, referred to under the head of cerebral 
haemorrhage, but applies only to dilatations of the larger ar- 
teries. According to Gouguenheim, 3 they are more common 
between the ages of fifty and sixty than at other periods of 
life, though cases were met with under the age of puberty. 
Tables given by Durand 3 are to the same effect, as is like- 
wise the experience of Lebert, 4 Gull, 6 and others. This is 
what might be expected from the known proclivity of the 
arteries to disease after the age of fifty. 

Sex appears to exert but little influence, though aneu- 
risms of the cerebral arteries seem to be somewhat more fre- 
quent with men than women. 

1 Op. cit., page 247. 

2 Des Tumeurs anevrysmales des arteres du Cerveau. These de Paris, 1866, 
p. 12. 

3 Des anevrysmes du Cerveau. These de Paris, 1868, p. 87. 

4 Klinische Wochenschrift, Berlin, Nos. 20 to 42, 1866. 

5 Guy's Hospital Reports, third series, vol. v., 1859, p. 281, et seq. 



312 DISEASES OF THE BRAIN. 

As exciting causes, blows on the head, falls, sudden and 
great physical exertion, intense emotion, or mental labor, 
embolism, and concentric hypertrophy of the heart, are to 
be mentioned. 

Parasitic tumors are caused by the migration of the em- 
bryos of the cysticercus and echinococcus from other parts of 
the body. 

Diathetic tumors are either cancerous, tuberculous, or 
syphilitic in character. The first named are more common 
during the adult period of life than any other, though they 
are met with at all ages. Although women are more sub- 
ject to some forms of cancerous tumors than men, yet in the 
brain they are far more common in the male sex. Of forty- 
eight cases studied by Lebert, cancer of the brain was primary 
in forty-five, that is, made its first appearance in this organ. 

Ogle, 1 of twenty-five cases of cerebral cancer, found that 
in thirteen the disease was confined to the brain, while, 
on the other hand, contrary to the generally received opin- 
ion, Dr. Mackenzie Bacon 2 found but ten primary cases out 
of seventy-three. 

There is no doubt that cancer of the brain is sometimes 
the result of traumatic cause. 

Tuberculous tumors of the brain are generally met with 
in young children, though they do occur, as in the case re- 
lated by Dr. Flint just cited, in adults. They are almost 
always secondary to similar products in the lungs. 

Syphilitic tumors are, of course, the result of the syphi- 
litic infection of the system. 

Accidental tumors may be caused by injuries, as was 
probably the case in one of the instances cited. Jaccoud, 
however, expresses the opinion that such an apparent relation 
is purely accidental, and that all we know of their etiology 
is that they are more common after the age of forty than be- 
fore that period. 

1 British and Foreign Medico-Chirurgical Review, July, 1865, p. 223. 

2 On Primary Cancer of the Brain, London, 1865. 



TUMORS OF THE BKAIN. 313 

Diagnosis. — The diagnosis of cerebral tumors is sometimes 
almost self-evident, in others it is equally impossible. This 
difference is due, not only to the various situations they 
may occupy, but also to their diverse nature. 

The presence of severe pain in the head for a long time 
is of itself some indication of the existence of a tumor if it 
is unaccompanied by febrile excitement. Epileptiform con- 
vulsions, occurring after the age of forty, should excite sus- 
picion that their cause is to be found in a morbid growth of 
some kind. The character of the convulsive seizures will 
aid us in forming an opinion of their etiology. "When pro- 
duced by a tumor they are generally unilateral, the loss of 
consciousness is not so complete, and there is rarely subse- 
quent stupor. The diagnosis from epilepsy is rendered 
more evident by the fact that, in tumor, the convulsions are 
seldom accompanied by mental weakness, and never by 
periods of active unconsciousness. From softening the dis- 
tinction can be made without much difficulty in the majori- 
ty of cases. The acute pain, the integrity of the mind, and 
the absence of general paresis, will usually suffice. But 
sometimes the discrimination cannot be made, for there are 
cases of tumors in which there is very little pain, in which 
the mind is involved, and in which the paralysis is not very 
strongly marked. 

The occurrence of very limited paralysis points to the 
existence of a tumor, rather than any other affection. A 
gentleman is now under my care, who, several years ago, 
had a cerebral haemorrhage, from which he was rendered 
hemiplegic. He regained to a great extent his mental and 
physical powers, but a few days ago suddenly had diplopia 
from paralysis of the external rectus muscle of the left eye, 
by which internal strabismus was produced. As yet there 
have been no other head-symptoms except vertigo, with 
which he has suffered a great deal in the last two years, and 
which was excessive when the diplopia appeared. In other 
respects the health is good, and the mind gives no evidence 



314 DISEASES OF THE BRAIN. 

of being affected. The paralysis of the external rectus is on 
the same side with the general hemiplegia. 

In my opinion, though I express it, of course, without 
positiveness, there is an aneurismal tumor pressing upon the 
sixth nerve after its emergence from the medulla oblongata, 
and probably affecting the left internal carotid artery. If 
this view be correct, other symptoms will certainly arise ere 
long. These will probably consist in the more extensive 
implication of cranial nerves, and in the supervention of 
hemiplegia. 

The diagnosis of the character of the tumor is of interest, 
and sometimes of importance with a view to the prognosis. 

Aneurismal tumors are more common in persons of ad- 
vanced age than in the young, they are more frequently ac- 
companied by vertigo, and they are more generally indicated 
by paralysis of one or more of the cranial nerves. The men- 
tal symptoms are not often marked. 

Parasitical tumors usually first manifest themselves by 
the occurrence of epileptiform convulsions, and the mental 
faculties do not long remain unaffected, for the reason that 
such products are more commonly seated in the gray sub- 
stance of the brain than in the white tissue or the ganglia at 
the base. As these latter generally escape, troubles of mo- 
tility are rare. Diathetic tumors are more easily recognized 
than any others, for the reason that we have other evidence 
of the existence of constitutional infection in the great major- 
ity of cases. As regards cancer, however, this aid is not gen- 
erally afforded, the affection being usually primary, and not 
producing the ordinary indications of the cancerous cachexia. 
But, as in the case cited in full, and the others referred to, 
the existence of an external tumor is some indication, in con- 
nection with head-symptoms, that there is a corresponding 
growth within the cranium. 

Tubercle may be suspected in cases presenting the symp- 
toms of cerebral tumor, when there are indications of simi- 
lar deposits in the lungs or other parts of the body, when 



TUMORS OF THE BRAIN. 315 

the subject exhibits evidence of possessing the tuberculous 
diathesis, or when the history shows hereditary tendency. 

In a patient presenting the symptoms of a tumor of the 
brain, its nature may safely be considered syphilitic, if, in 
addition, his clinical history shows that he is tainted with 
syphilis, or has, at some former period, suffered from it. 

In regard to accidental tumors or those of various ana- 
tomical characteristics, there is not much to be said of their 
diagnosis. There are no means by which one species can 
be distinguished from another, and no positive indications 
which can enable us to discriminate them from other tu- 
mors, except by the way of exclusion. 

Prognosis. — Cerebral tumors uniformly lead to a fatal re- 
sult, except they be syphilitic in character. In these latter 
there is a very considerable prospect of recovery if the prop- 
er medical treatment be adopted. 

Morbid Anatomy and Pathology. — Vascular Tumors. — 
The most common seat of cerebral aneurisms is the basilar 
artery, and they are larger here than when any other vessel 
is affected. Gouguenheim * gives the following table, based 
upon sixty-eight cases : 

Basilar 17 cases. 

Middle cerebral 14 

Internal carotids 12 

Anterior cerebral 8 

Posterior communicating 5 

Cerebellar 4 

Anterior communicating 2 

Posterior cerebral 3 

Middle meningeal 2 

Arterio-venous 2 

Cerebral aneurisms do not differ in any essential particu- 
lar from similar formations in other parts of the body. They 
are, however, smaller, rarely being as large as a walnut, and 

1 Op. cit., page 21. 



316 



DISEASES OF THE BRAIN. 



generally ranging in size from that of a cherry-stone to that 
of an almond. 

Lebert ascertained that they were more frequently met 
with in the arteries of the left side of the brain than in those 
of the right. Gouguenheim confirms this observation. Thus 
of forty-one cases in which the side was determined, twenty- 
seven were on the left, and fourteen on the right. This dif- 
ference is doubtless in part at least due to the fact that one 
of the causes of cerebral aneurisms, embolus, is more common 
on the left side than on the right. In a very interesting 
paper, Prof. "W. P. Smith * calls attention to the fact that 
aneurisms of the encephalic arteries may be thus produced. 
The following figure, which I take from his memoir, gives 
an excellent illustration of such an aneurism in the left mid- 
dle cerebral artery : 

Fig. 11. 2 




In regard to the post-mortem examination of the patient, 
from whom the preparation was taken, Prof. Smith says : 

" Upon tracing the left middle cerebral artery into the 
fissure of Sylvius, it was found to be obstructed (just where 
it branches into twigs surrounding the island of Reil) by a 
plug of fibrine of a yellowish color and oblong form, fully a 
quarter of an inch in length and about the eighth of an inch 

1 Cerebral Aneurism. Reports of the Dublin Pathological Society. Dublin 
Quarterly Journal of Medical Science, November, 1870, p. 443. 

2 The drawing shows the position of the aneurism reversed to the right side. 



TUMORS OF THE BRAIN. 317 

in breadth. At the seat of obstruction the vessel was di- 
lated into an oblong tumor half an inch in length and a 
quarter of an inch broad, the space intervening between the 
original plug and the arterial tunics being occupied by co- 
agulated blood." 

The theory sustained by Prof. Smith was, as he freely 
states, first proposed by Dr. Senhouse Kikes * in the paper to 
which I have already referred under the head of embolism. 

The idea was formerly very generally entertained, that 
cerebral aneurisms were always true, that is, caused by the 
uniform dilatation of all the coats of the artery. Hodgson 3 
sustained this view on the ground that the tunics of the en- 
cephalic arteries were of such extreme tenuity that they 
readily dilated, and Albers, 3 Crisp, 4 Gull, 5 and others, held 
similar opinions, but the recognition of the fact that the 
arteries of the brain are peculiarly subject to disease in per- 
sons advanced in age, and the researches of Lebert, Yir- 
chow, and Kolliker, go to show that such a view is errone- 
ous. Three other kinds are known to exist, the mixed ex- 
ternal in which the interior and middle coats are ruptured 
and the sac is formed by the external coat ; the dissecting, in 
which the internal tunic is ruptured and the blood is to a 
certain extent forced between the layers of the middle tunic ; 
and the arterio-venous. This latter is seated in the caver- 
nus sinus, and is produced by the rupture of a small carotid 
aneurism, or it is the result of wound or injury. 

Aneurismal tumors may cause death either by the press- 
ure which they exert on important parts of the brain or by 
the giving way of the sac and the consequent extravasation 
of blood, producing pressure and disorganization. 

Parasitic tumors are of two kinds, those produced by the 

1 Medico-Chirurgical Transactions, vol. xxxv., p. 852. 

2 A Treatise on the Diseases of Arteries and Veins, London, 1815 

3 Memoire sur les Anevrysmes du Cerveau et ses Meninges, Bonn, 1836. 

4 A Treatise on the Structure, Diseases, and Injuries of the Blood-vessels, 
London, 1847. 

5 Guy's Hospital Reports, 1857. 



318 DISEASES OF THE BRAIN. 

cysticercus and those caused by the echinococcus or hydatids. 
The former are small, scarcely ever being larger than a small 
bean. They are rarely encysted, as in other parts of the 
body, but are in close apposition with the brain-substance. 
They are generally met with in numbers ranging from ten 
to twenty. Cruveilhier x reports a case in which there were 
over one hundred. 

They are found in all parts of the cerebrum and cerebel- 
lum ; fifty of those discovered by Cruveilhier, in the case 
just cited, were in the cerebellum. Generally they are 
near the surface of the brain — often in the pia mater, in 
which situation they press upon the gray matter, and often 
in this latter substance. When situated in the ventricles, 
there is less impediment to the growth of the parasite, and 
hence it may become developed into a more or less perfect 
tape-worm. 

Cobbold a states that there are about one hundred cases 
on record of cysticerci being found in the brain after death. 
Of these, Griesinger 3 reports between fifty and sixty. 

Echinococci, or hydatids, though much larger than the 
foregoing-described parasites, are less numerous. Gener- 
ally there is only one, and rarely are there two cysts. Each 
cyst may contain a single hydatid, as is usually the case, or 
there may be more in different stages of growth. In size, 
the cysts vary from that of a marble to that of an orange, 
and consist of a vascular membrane enclosing the parasite. 

Of one hundred and thirty-three cases occurring in the 
human subject and analyzed by Cobbold, sixteen were situ- 
ated in the brain. All were of course fatal. 

Both of these species of parasitical tumors may be pri- 
mary, or they may be accompanied by similar growths in 
other parts of the body. 

1 Anat. Pathol. Gen., t. ii., p. 83, Paris, 1852. 

2 Entozoa : An Introduction to the Study of Helminthology, with Reference 
more particularly to the Internal Parasites of Man, London, 1864. 

3 Cysticerken und ihre Diagnose, Archiv der Heilkunde, 1862. 



TUMORS OF THE BRAIX. 319 

Diathetic tumors are either cancerous, tuberculous, or 
syphilitic. 1 

Cancer may affect any part of the brain, though it more 
generally attacks the hemispheres, the cerebellum, the optic 
thalami, the corpus striatum, or the pons Varolii. It may 
begin in the bones of the cranium, in the membranes, or in 
the brain itself. A common seat is the orbit. According 
to Dr. Mackenzie Bacon, of seventy-three cases of brain- 
tumors occurring in the London hospitals during the period 
from lS5i to 1863, ten were cancerous. Ladame, 2 of three 
hundred and thirty-nine cases of cerebral tumors, collected 
from various sources, found that sixty-seven were cancerous. 

The dimensions of cancerous tumors are very variable. 
Generally they do not much exceed the size of an English 
walnut, though they may be twice as large. 

Either variety of cancer, encephaloid, scirrhous, or col- 
loid, may have its seat in the brain. Primitive cancer is 
usually single ; secondary, multiple. In a case reported by 
Dr. Webber, 3 of Boston, in which there was a preexisting 
cancerous tumor of the vagina, the brain was found to con- 
tain several deposits of cancerous growths — one quite 
large, situated in the left hemisphere, and two in the cere- 
bellum. 

Ogle 4 has shown that the brain-substance surrounding 
the cancerous growth undergoes softening. Frequently it 
is not changed at all. 

The tumor itself does not often undergo softening, but a 
kind of fatty degeneration and atrophy occur, and the tissue 
becomes hard and compact, with no traces of blood-vessels 
remaining. 

Tubercular tumors may be either single or multiple. In 
the former case, they are often as large as a cherry ; in the 

1 Op. cit. 

5 Symptomatologie und Diagnostic der Hirngeschwiilste, Wiirzburg, 1865. 

3 Journal of Psychological Medicine, vol. iv., 1870, p. 569. 

4 Journal of Mental Science, 1864, p. 229. 



320 DISEASES OF THE BRAIN. 

latter, they may be as small as a grain of wheat. Very 
large tubercular tumors result from the fusion of two or more 
smaller ones. They are generally seated in the hemispheres 
or cerebellum, though the other parts of the encephalon are 
not exempt. They are the most frequently met with of 
all the forms of cerebral tumors. 

Syphilitic tumors are in general seated in the mem- 
branes, or in these and the gray matter. They are very 
rarely entirely confined to the substance of the brain, and 
are never encysted. They are, therefore, not distinctly cir- 
cumscribed, but the elements of which they are composed 
are infiltrated into the surrounding brain-tissue. In size 
they vary, rarely being as large as a walnut. Histologically 
they consist of nuclei and cells. The former contain nucle- 
oli and occupy the periphery of the tumor, while the cells 
are found mainly in the centre. Syphilitic tumors are or- 
dinarily accompanied by like growths in other parts of the 
body, especially the lungs and liver. 

Accidental Tumors. — Under this head are included all 
formations not diathetic or vascular. Among them are the 
fibro-jplastic tumors, which may attain to the size of an 
orange and which are generally growths from the dura 
mater at the external part of the base of the cranium. They 
are composed of fusiform cells, nuclei, and blood-vessels. 
They are of variable consistence, sometimes being almost 
fluid, and at others gelatiniform in character. 

Under the name of gliomata, Yirchow described a cere- 
bral growth due to an abnormal development of the neuro- 
glia or connective tissue of the brain. They are more gen- 
erally found in the posterior cerebral lobes, and may attain 
to the size of an orange. Usually there is but one. There 
are two kinds of these tumors, one soft, being about the con- 
sistence of the brain-substance, the other much harder. 
They consist of cells and nuclei, but never contain any of the 
nervous elements. Cholesteatomata, sometimes called pearly 
tumors, may arise from the cranial bones, from the mem- 



TUMORS OF THE BRAIN. 321 

branes, or from the brain itself. They rarely attain to the 
size of a walnut, and are generally very much smaller. His- 
tologically they consist of a limiting membrane of extreme 
tenuity, the contents of which are disposed in concentric 
layers. These strata are epidermic cells which have under- 
gone degeneration. There are no vessels either in the envel- 
ope or the contents, which, in addition to the elements just 
mentioned, consist of cholestrine and stearine. 

In addition to these there are osseous tumors (exostoses), 
growing from the cranial bones, and which may or may not 
be syphilitic, lipomatous, enchondromatous, mucous, and 
several other species of tumors, which are treated of fully in 
the special monographs on the subject, but which need not 
detain us in the present connection. 1 

Two bodies cannot occupy the same space at the same 
time. In a state of health, the brain so nearly fills the cra- 
nial cavity that there is barely room for those variations in 
the amount of blood and ventricular fluid which occur with- 
in the normal limits. The growth of a tumor, therefore, is 
at the expense of the brain. As the former increases in size, 
the latter diminishes, and hence some of the symptoms re- 
sulting from tumors are similar to those which follow atro- 
phy or sclerosis. Besides, we have other consequent effects, 
such as oedema, congestion, anaemia, haemorrhage, inflamma- 
tion, or softening. 

When cerebral tumors press upon the cranial nerves they 
produce fatty degeneration and atrophy. This effect is 
manifested by alterations of sensibility or of motility in the 
parts supplied by these nerves. In the eyes, however, in ad- 
dition, the changes can be seen with the ophthalmoscope. 
They consist in the main of atrophy of the optic disk, disap- 

1 For a very full and complete essay on the subject of Cerebral Tumors, the 
reader is referred to Dr. J. W. Ogle's cases illustrating the Formation of Mor- 
bid Growths, Deposits, Tumors, Cysts, etc., in connection with the Brain and 
Spinal Cord and their investing Membranes, British and Foreign Medico-Chirur- 
gical Review, 1 864-' 65. 
21 



322 DISEASES OF THE BRAIN. 

pearance of the vessels, congestion of the retina, or haemor- 
rhage or serous infiltration with detachment. As Jaccoud 
remarks, easily appreciated by the ophthalmoscope, these 
lesions have a real importance in clinical diagnosis. 

As to the relation between the symptoms and the seat 
of the lesion, the principles enunciated under the head of 
cerebral haemorrhage are applicable to cerebral tumors. 

Treatment. — There is no treatment calculated to cure the 
patient, unless a syphilitic taint can be ascertained. It is 
well, however, even when there are no positive indications 
of the existence of such a diathesis, to act upon the presump- 
tion that it does exist, and to administer mercury in some 
form with the iodide of potassium. By adopting this prin- 
ciple, I have several times succeeded in curing patients who 
exhibited the most positive indications of suffering from tu- 
mor of the brain. One very remarkable case was that of a 
gentleman who consulted me several months since for ptosis, 
double vision, dilatation of the pupil, vertigo, and cephalal- 
gia. The opinion was expressed by other physicians that 
there was a cerebral tumor, and I entirely accorded with 
the view. The gentleman had no recollection of ever hav- 
ing had a chancre of any kind, but I nevertheless adminis- 
tered the bichloride of mercury and iodide of potassium, ac- 
cording to the following formula : 1$ . hyd. bichlor. (corros), 
grs. ij, potass, iodidi 3 v, aquae 5 i y > M. ft. sol. Dose, tea- 
spoonful three times a day. At the next visit of the patient 
he remembered that when in China, several years previ- 
ously, he had contracted a chancre for which he was treated. 
I continued the treatment, conjoining it with the use of elec- 
tricity to the eye so as to act upon the paralyzed muscles, 
and had the satisfaction to see a gradual but steady im- 
provement take place, till eventually in the course of a few 
weeks the cure was complete. 

Another case was that of a lady who consulted me in 
July, 1870, for agonizing pain in the head, vertigo, and pa- 
ralysis of the third nerve of the left side, the latter producing 



TUMORS OF THE BRAIN. 323 

ptosis, external strabismus, and consequent diplopia. I could 
discover no evidence of syphilis, but I nevertheless adminis- 
tered the bichloride of mercury and the iodide of potassium, 
as in the foregoing case. The induced or faradaic current 
was applied to the eye, and the patient soon began to mend. 
The headache disappeared first, then the vertigo, and event- 
ually the paralysis. Subsequently I ascertained from the 
lady's husband that it was barely possible he might have in- 
fected his wife. I have no doubt whatever that he did. 

The medication recommended can do no harm. There 
is, therefore, no reason why the patient should not have the 
chance of being benefited by it. 

The prescription mentioned is a very eligible form for 
administering both the mercury and iodide of potassium. 
Salivation is never caused by it, and the stomach generally 
tolerates it well. Of course the proportions of the ingredi- 
ents can be altered, as may seem best in individual cases. 

The induced galvanic current is beneficial in restoring 
contractility to the paralyzed muscles. When applied to 
the eye the lids should be closed, one electrode, a wet sponge, 
is placed on them, the other is held in the hand or placed 
on the nape of the neck, and a current not so strong as to 
cause any considerable pain is then allowed to pass through 
the intervening tissues. For the relief of the pain attend- 
ant on cerebral tumors, morphia may be administered hypo- 
dermically, or, what I have found advantageous in several 
cases, the extract of Indian hemp, as recommended by Rey- 
nolds, may be used. 

Counter-irritation, as produced by the actual cautery or 
other less powerful means, can do no possible good, and 
only adds to the discomfort of the patient. 



CHAPTEE XV. 

INSANITY. 
GENERAL PRINCIPLES. 

The brain is the chief organ from which the force called 
the mind is evolved, and, so far as the present inquiry goes, 
may be regarded as the only one. For, though, wherever 
there is gray nerve-tissue, nervous force is generated, and 
though all nervous force partakes more or less of the charac- 
ter of that which we call mind, its qualities are not of such 
a nature as to bring their aberrations within the scope of 
this chapter. 

By mind, therefore, we understand a force developed by 
nervous action, and especially by the action of the brain. 
The modifications which this force, in its cerebral relations, 
undergoes outside of the limits of health, either as regards 
excess, deficiency, or variation of quality, are embraced un- 
der the term insanity. Some authors have doubted the 
connection between the brain and the mind. Though we 
all feel that the relation does exist, it is perhaps as well to 
state briefly the facts which tend to establish the dependence 
of the one upon the functionation of the other. They have 
been well set forth by Mr. Bain : 1 

1. The action of an organ, even within the limits of 
health, frequently gives rise to sensations of various kinds, 

1 The Senses and the Intellect, second edition, London, 1864, p. 11. Also 
Mental and Moral Science ; a Compendium of Psychology and Ethics, London, 
1868, p. 5. 



INSANITY. 325 

and slight functional derangements are very distinctly felt. 
Thus, the pain of indigestion is referred to the stomach or 
bowels, as the case may be ; difficulties with the urinary ex- 
cretion cause uneasiness in the kidneys ; derangements in 
the secretion of the bile cause pain in the liver ; loud noises 
produce unpleasant feelings in the ears, and excessive or im- 
proper use of the eyes causes pain in these organs. So it is 
with the brain. Though ordinarily we are not conscious by 
any particular sensation that we are using it when we think 
(and the same is true mutatis mutandis of the other organs 
mentioned), yet inordinate mental exertion gives rise to 
headache, vertigo, and other derangements of sensibility, re- 
ferable to the brain. I have had many patients under my 
charge in whom very slight mental action invariably pro- 
duced pain in the head. It is well known that the brain 
becomes diseased when it is unduly taxed, just as does the 
spinal cord, the eye, or a muscle. 

2. Injury or disease of the brain impairs in some way or 
other the powers of the mind. A blow on the head causes 
confusion of thought, and, if hard enough, may abolish con- 
sciousness or the power of thought altogether. A piece of 
fractured bone, or a bullet, pressing on the brain, likewise 
destroys the ability to think ; and though, as in cases cited 
in another part of this treatise, there are examples of ter- 
rible wounds of the brain without, for a time, notable im- 
pairment of the mind, there is some loss from the first, 
and eventually the patients die with head-symptoms. The 
various affections of the brain which have been considered 
in this treatise, without exception produce, at some time or 
other of their course, derangement in the evolution of mind. 
Insanity, too, very often is shown, after death, to have been 
accompanied by structural changes in the brain. 

3. The action of the. brain, like that of other organs, 
results in the disintegration of its substance, and this de-~ 
struction of tissue is in direct proportion to the amount of 
mental work done. We find, therefore, that the alkaline 



326 DISEASES OF THE BRAIN. 

phosphates, which are mainly derived from the destructive 
metamorphosis of the nervous tissue, and which are excreted 
by the kidneys, are increased in quantity after severe intel- 
lectual labor, and are diminished by mental quietude. In 
a memoir published several years ago, I gave the results of 
a series of experiments performed upon myself, whicli show 
very conclusively that increased use of the brain causes in- 
creased decay. 1 

4. The size of the brain is well known to bear a direct 
relation to the intelligence of the individual ; and, when all 
other conditions are alike, it may be said that the largest 
brain will produce the greatest amount of mental energy. 
Quality is, however, also an important factor, and when 
with great size we also have a large amount of gray matter, 
the intellectual capacity is at its maximum. 

Thus, Dr. Thurnam 2 has shown that the average weight 
of the brain in Europeans is 49 ounces, while in ten men 
remarkable for their intellectual development it was 54.7 
ounces. Of these, the brain of Cuvier, the celebrated natu- 
ralist, weighed 64.5 ounces, Spurzheim's 55.06, and Daniel 
Webster's 53.5. On the other hand, the brain is small in 
idiots. In three idiots whose ages were sixteen, forty, and 
fifty years, Tiedemann found the weight of their respective 
brains to be 19f , 25f , and 22J ounces. Mr. Gore 3 has re- 
ported the case of a woman, forty-two years of age, whose 
intellect was infantine, who could scarcely say a few words, 
whose gait was unsteady, and whose chief occupation was 
carrying and nursing a doll. After death, her brain, care- 
fully weighed, was found to weigh but 10 ounces and 5 grains. 

Mr. Marshall 4 has also reported a case of microcephaly 

1 Urological Contributions, American Journal of the Medical Sciences, April, 
1856, p. 330. Also Physiological Memoirs, Philadelphia, 1863, p. 17. 

2 Journal of Mental Science, April, 1866. 

3 Notes of a Case of Microcephaly, Anthropological Review, No. 1, May, 
1863, p. 168. 

4 Brain and Calvarium of a Microcephale. Transactions of the Anthropo- 
logical Society of London, in Anthropological Review, No. 2, August, 1863, p. 8. 



INSANITY. 327 

existing in the person of a boy twelve years old, whose brain 
weighed but 8£ ounces. The convolutions were strongly 
marked, though few in number and narrow. 

5. Experiments performed upon the nerves and nerve- 
centres show that from the brain proceeds the force by 
which muscles are moved, and that it is the organ by which 
sensations are perceived. Thus, division of a nerve supply- 
ing a certain muscle cuts off the connection between the 
brain and that muscle, and hence the will can no longer act 
upon it. Division of the optic nerve, for instance, prevents 
the perception of visual images. 

From all of which considerations the connection between 
the brain and the mind is as clearly made out as any other 
fact in physiology. 

The mind differs from forces in general, in being com- 
pound ; that is, in being made up of several other forces. 
These are perception, the intellect, the emotions, and the 
will. All the mental manifestations of which the brain is 
capable are embraced in one or more of these parts. Ei- 
ther one of them may be exercised independently of the 
other, though they are very intimately connected, and in all 
continuous mental processes are brought more or less into 
relative and consecutive action. As constituting the basis 
of my classification of the several forms of insanity, it is ex- 
pedient to describe these four sub-forces of the mind. 

1. Perception. — By perception is to be understood that 
part of the mind whose office it is to place the individual in 
relation with external objects. For the evolution of this 
force the brain is in intimate relation with certain special 
organs which serve the purpose of receiving impressions of 
objects. Thus an image is formed upon the retina, and the 
optic nerve transmits the excitation to its ganglion or part 
of the brain. This at once functionates, the force called 
perception is evolved, and the image is perceived. If the 
retina be sufficiently diseased, the image is not formed ; if 
the optic nerve is in an abnormal condition, the excitation is 



328 DISEASES OF THE BRAIN. 

not transmitted ; if the ganglion be disordered, the percep- 
tive force is not evolved. 

Like reasoning is applicable to the other senses — hear- 
ing, taste, smell, and touch. 

Perception may be exercised without any superior in- 
tellectual act — without any ideation whatever. Thus, if the 
cerebrum of a pigeon be removed, the animal is still capa- 
ble of seeing and of hearing, but it obtains no idea from 
these senses. The mind, with the exception of perception, 
is lost. 

2. The Intellect. — In the normal condition of the 
brain the excitation of a sense and the consequent percep- 
tion do not stop at the special ganglion of that sense, but 
are transmitted to a more complex part of the brain where 
the perception is resolved into an idea. Thus the image 
impressed upon the retina, the perception of which has been 
formed by a sensory ganglion, ultimately causes the evolu- 
tion of another force by which all its attributes capable of 
being represented upon the retina are more or less perfect- 
ly appreciated according to the structural qualities of the 
ideational centre. To the formation of the idea several im- 
portant faculties and modes of expression of the intellect 
contribute. 

Thus, if we suppose the retina to have received the 
image of a ball, a higher ganglion converts this into a per- 
ception, and a still higher one into an idea ; and this idea 
relates to the size, the form, the color, the material, etc., 
primarily, and the origin, uses, ownership, etc., secondarily. 
In gaining this conception of the thing impressed upon the 
retina, the memory, judgmenjt, and other faculties of the in- 
tellect are brought into action, and the process of reasoning 
is carried on. 

3. The Emotions. — An idea in its turn excites another 
part of the brain to action, and an emotion is produced, or 
this last-named force may be evolved under certain circum- 
stances without the intermediation of the idea, but solely 



INSANITY. 329 

from the transmission of a perception to the emotional gan- 
glion. 

An emotion is that pleasurable or painful feeling which 
arises in us in consequence of sensorial impressions or intel- 
lectual action. According to Bain, the word emotion is used 
to comprehend all that is understood by feelings, states of 
feeling, pleasure, pain, passion, sentiments, affection, etc. 

"Within the limits of health the emotions act powerfully 
on certain organs of the body, and thus express their own 
activity. Thus grief is exhibited by the flow of tears from 
over-excitation of the lachrymal gland; extreme joy may 
also cause weeping; the jaw falls, and the angles of the 
mouth curve downward in mortification or sorrow, while in 
pleasure the face expands laterally. The eyes, the nose, 
and the mouth, are the three facial centres from which emo- 
tional expression is mainly produced. Other organs of the 
body, as the salivary glands, the heart, the mammary glands, 
the liver, the kidneys, and, in fact, nearly every viscus of 
the body, may exhibit the effects of emotion by the trans- 
mission of excitations through the sympathetic nerve. Most 
of the resulting effects are due to the fact that the sympa- 
thetic nerve especially presides over the vaso-motor system, 
and thus regulates the calibre of the blood-vessels. 

The "Will. — By volition acts are performed. Some acts 
are automatic, but all done in consequence of intellection 
are the result of willing, and are for some specific purpose 
connected with an idea. Yolition in the series of mental 
manifestations may precede emotion, but it always follows 
ideation. 

To sum up these outlines : A person walking in the 
street sees a man on the opposite side of the way — Percep- 
tion ; he recognizes him as a friend whom he has not met 
for many years — Intellect; he determines to go across and 
speak to him — Will; he does so, and exhibits joy at the 
reunion — Emotion. 

Or, to alter the sequence somewhat : 



330 DISEASES OF THE BRAIN. 

A person at a theatre sees and hears an actor on the 
stage — Perception ; the attitudes, gestures, and words of 
the player call up certain ideas — Intellect ; he is moved to 
great joy or grief — Emotion / and, determining to recognize 
the ability of the actor — Will, claps his hands, or throws 
him a bouquet. 

The mind, therefore, as before stated, is a compound 
force evolved by the brain, and its elements are perception, 
intellect, emotion, and will. The sun likewise evolves a 
compound force, and its elements are light, heat, and actin- 
ism. One of these forces, light, is again divisible into sev- 
eral primary colors, and the intellect of man, one of the 
mental forces, is made up of faculties. It would be easy to 
pursue the analogy still further, but enough has been said 
to indicate how clearly the relationship between brain and 
mind is that of matter and force. 

In individuals whose brains are well formed, and free 
from structural changes, and are nourished with a due sup- 
ply — neither excessive nor deficient — of healthy blood, the 
perception, the intellect, the emotions, and the will, act in a 
manner common to mankind in general. SKght changes in 
the formation or nutrition of the brain induce corresponding 
changes in the several parts of the mind, or in it as a whole. 
As no two brains are precisely alike, so no two persons are 
precisely alike in their mental processes. So long, however, 
as the deviations are not directly at variance with the aver- 
age human mind the individual is sane. If they are at va- 
riance, he is insane. But within the limits of mental health 
marked irregularities are met with in different parts of the 
mind. Thus some persons are noted for never perceiving 
things as the majority of people perceive them. Others 
have the emotional system inordinately or deficiently de- 
veloped. Others are weak in judgment, defective in mem- 
ory, feeble in powers of application, or vacillating in their 
opinions. Others, again, are lacking in volitional power — 
in the ability to perform certain acts, to refrain from others, 



INSANITY. 331 

or to follow a definite course of action which the intellect 
tells them is expedient and wise. 

Eccentricity. — Persons whose minds deviate in some one 
or more notable respects from the ordinary standard, but 
yet whose mental processes are not directly at variance with 
that standard, are said to be eccentric. It is not always 
easy to draw the line between strong eccentricity and mild 
insanity. About the former, however, there is this marked 
characteristic : that its manifestations are according to a 
fixed system, are not founded on delusions, and are gener- 
ally excited by those emotions or desires which are reflected 
back to the individual, such as vanity, pride, the love of ap- 
probation, or of notoriety, etc. Eccentric persons stand 
upon the verge of insanity with a decided predisposition to 
mental disease, and ordinarily do not pass the limit merely 
for want of a sufficient exciting cause. Several instances of 
eccentricity passing into undoubted insanity have come 
under my observation. In one of these, a lady had since 
her childhood shown a singularity of conduct as regarded 
her table-furniture, which she would have of no other ma- 
terial than copper. She carried this fancy to such an extent 
that even the knives were made of copper. People laughed 
at her, and tried to reason her out of her whim, but in vain. 
In no other respect was there any evidence of mental aberra- 
tion. She was intelligent, by no means excitable, and in 
the enjoyment of excellent health. An uncle had, however, 
died insane. A trifling circumstance started in her a new 
train of thought, and excited emotions which she could not 
control. She read in the morning paper that a Mr. Kop- 
perman had arrived at one of the hotels, and she announced 
her determination to call on him. Her friends endeavored 
to dissuade her, but without avail. She went to the hotel, 
and was told he had just left for Chicago. Without return- 
ing to her home, she bought a ticket for Chicago, and ac- 
tually started on the next train for that city. The tele- 
graph, however, overtook her, and she was brought back 



332 DISEASES OF THE BEAIN. 

from Rochester, raving of her love for a man she had never 
seen, and whose name alone had been associated in her 
mind with her fancy for copper table-furniture. She died 
of acute mania within a month. 

In another case a young man, a clerk in a city bank, had 
jfor several years exhibited peculiarities in the keeping of 
his books. He was exceedingly exact in his accounts, but 
after the bank was closed for the day he always remained 
several hours, during which he ornamented each page of his 
day's work with arabesques in different-colored inks. His 
fellow-clerks amused themselves at his expense, but his su- 
perior officers, knowing his value, never interfered with him 
in his amusement. Gradually, however, he conceived the 
idea that they were displeased with him, and at last this be- 
came so firmly rooted in his mind that he resigned his posi- 
tion, notwithstanding the protestations of the directors that 
his idea was erroneous. Delusions of various kinds soon 
supervened, and he is now hopelessly insane. 

Inquiry will frequently disclose the fact that the insane 
have been eccentric for several years before becoming 
affected with cerebral disease to such an extent as to pro- 
duce decided mental aberration. 

Definition of Insanity. — Every medical witness, who ap- 
pears in a case involving the mental capacity or responsi- 
bility of an individual, is expected to give a definition of in- 
sanity. It is extremely difficult to do this satisfactorily, as 
it is also with a great many other terms which are applied 
to complex forces. It is difficult to give such a meaning to 
the word as will cover all possible cases of deficiency or ab- 
erration of the mental faculties, and yet not include those 
instances of cerebral disease which cannot properly be 
classed under this head. For the purpose of showing how 
authors have varied in their ideas of the signification of the 
word, as well as for the instruction of the reader seeking for 
information on the point, I quote a number of definitions 
from some of the most eminent authorities : 



INSANITY. 333 

Dr. John Haslam, 1 who has written one of the most 
lucid treatises on insanity in the English language, and 
who was for many years one of the physicians to Bethlehem 
Hospital, confesses his inability to give a thoroughly com- 
prehensive and yet a sufficiently exclusive definition of mad- 
ness ; and Dr. Prichard a frankly admits that it is better to 
give up the attempt to define insanity in general terms. 
Notwithstanding the reluctance of these and other medical 
authorities to formularize the phenomena of insanity, the at- 
tempt has frequently been made with more or less approach 
to completeness. If the word can be even imperfectly de- 
fined in simple language without conveying erroneous ideas, 
it is certainly advisable to make an effort in this direction. 

According to Hoffbauer, 8 an individual is insane when 
the understanding is diverted or changed in its operations ; 
when he is powerless to avail himself of his intellectual fac- 
ulties, or to make known his wishes in a suitable manner. 

This definition, though embracing all cases of insanity, 
is not satisfactory, for the reason that it is applicable to cer- 
tain cerebral disorders which are not properly classed under 
this head. Among these may be mentioned apoplexy, and 
concussion and compression of the brain. 

Dr. Bucknill, in his " Essay on Criminal Lunacy," defines 
insanity as " a condition of the mind in which a false action 
of conception or judgment, a defective power of the will, or 
an uncontrollable violence of the emotions and instincts 
has separately or conjointly been produced by disease." 
This definition is a very excellent one, but still includes 
those diseases of the brain attended with unconsciousness 
which are not insanity. 

Dr. Guislain, 4 an eminent Belgian authority, says that 

1 Observations on Madness and Melancholy, etc., second edition, London, 
1809, p. 37. 

9 Article Insanity, in Cyclopaedia of Practical Medicine. 

3 Untersuchungen iiber die Krankheiten der Seele. Halle, 1803, p. 11. 

4 Lecons sur les Phrenopathies, tome i., p. 45. 



334 DISEASES OF THE BRAIN. 

" insanity is a morbid derangement of the mental faculties 
unattended by fever, and chronic in its character, which 
deprives man of the power of thinking and acting freely as 
regards his happiness, preservation, and responsibility." 

The objections to this definition, in addition to those ap- 
plicable to the others given, are that insanity is not neces- 
sarily unaccompanied by fever, and that it is not always a 
chronic affection. 

Drs. Bucknill and Tuke, 1 quoting from Maimon, say 
that " mental health consists in that state in which the will 
is free, and in which it can exercise its "empire without ob- 
stacle. Any condition different to this is a disease of the 
mind, and if it is asked, What is the will ? it may be re- 
plied, according to the definition of Marc, that it is a moral 
faculty which originates, directs, prevents, or modifies the 
physical and moral acts which are submitted to it." 

The late Prof. Gilman, of this city, who had given a 
great deal of study to the subject, declared that the best 
definition he had been able to make was, that " insanity is 
a disease of the brain by which the freedom of the will is 
impaired." This has the advantage of being short and of 
being to the point. Other diseases, however, are included 
in its terms. 

It would be easy to go on and quote numerous other au- 
thorities on this point, but enough have been cited to show 
the general import which physicians give to the word in- 
sanity. I will therefore dismiss the further consideration 
of this division of the subject, by stating that my own idea 
of insanity is based entirely on the fact, that as the healthy 
mind results from a healthy brain, so a disordered mind 
comes from a diseased brain. Insanity, therefore, strictly 
speaking, is only a symptom, and I would define it as — 

A manifestation of disease of the brain, characterized by 
a general or partial derangement of one or more faculties of 

1 A Manual of Psychological Medicine, etc., London, 1858, p. 79. 



INSANITY. 335 

the mind, and in which, while consciousness is not abolished, 
mental freedom is perverted, weakened, or destroyed. 

An essential feature of the definition of insanity here 
given is, that it depends directly upon a diseased condition 
of the brain. This is the immediate cause, and may consist 
of structural changes due to injury, disease, or malforma- 
tion, or of malnutrition, the result of excessive intellectual 
exertion, the action of powerful emotions, irritations in dis- 
tant parts of the body, the sudden stoppage of the digestive 
process, the introduction into the system of certain drugs, 
such as opium, alcohol, belladonna, etc., the retention in the 
organism of substances poisonous in character, but which in 
health are excreted, and of other factors capable of altering 
the quantity or quality of the blood circulating through the 
cerebral vessels, or of accelerating or retarding the meta- 
morphosis of tissue which the brain undergoes in common 
with all the other organs of the body. These causes, with 
others, will be more fully considered hereafter. 

Classification. — Many classifications have been made of 
the several manifestations of insanity. As is well known, 
mental disease appears under different characters, just as 
does the healthy mind. Some authors have been exceed- 
ingly minute in their arrangement, making a type of the 
disease from each particular symptom or delusion the pa- 
tient may show. Others, again, are metaphysical and un- 
practical. 

The classification of Esquirol 1 has been very generally 
adopted, with more or less modification according to the 
peculiar ideas of the authors. Although arbitrary, and 
based upon the principle of regarding the symptom as the 
disease, it is certainly the best of its kind ; and, though made 
more than thirty years ago, is still followed by many writers. 
The terms employed by Esquirol are so frequently met with 
in works on insanity, that I give his classification as a part 
of the history of the subject : 

1 Des Maladies Mentales, tome i., p. 11, Paris, 1838. 



336 DISEASES OF THE BRAIN. 

1. Melancholia. — Perversion of the understanding in re- 
gard to an object or a small number of objects, with the 
predominance of sadness and depression of mind. 

2. Monomania. — Perversion of understanding limited to 
a single object or a small class of objects, with predomi- 
nance of mental excitement. 

3. Mania. — A condition in which the perversion of un- 
derstanding embraces all kinds of objects, and is attended 
with mental excitement. 

4. Dementia. — A condition in which those affected are 
incapable of reasoning, from the fact that the organs of 
thought have lost their energy and the force necessary for 
performing their functions. 

5. Imbecility or Idiocy. — A condition in which the or- 
gans have never been sufficiently well-conformed to permit 
those affected to reason correctly. 

One of the latest and most able writers on the subject 
of mental derangement is Dr. Maudsley, 1 and he classifies 
the several forms of insanity according to the mental symp- 
toms, as follows : 

I. — Affective ok Pathetic Insanity. 

1. Maniacal perversion of the affective life. Mania sine 

delirio. 

2. Melancholic depression without delusion. Simple melan- 

cholia. 

3. Moral alienation proper. Approaching this, but not 

reaching the degree of positive insanity, is the insane 
temperament. 

II. — Ideational Insanity. 
1. General. 

a, Mania. 

I, Melancholia, ) g^ 

1 The Physiology and Pathology of the Mind. London and New York, 1867, 
p. 323. 



INSANITY 337 

2. Partial. 

a. ^lonornania. 
h. Melancholia. 

3. Dementia, < ^ p ' 

( secondary. 

4. General Paralysis. 

5. Idiocy or Imbecility. 

In 1S67, an International Congress of Alienists was held 
in Paris, and a committee, appointed by that body to make 
a classification, reported the following : 

I. Simple insanity, embracing the different varieties of 
mania, melancholia, and monomania, circular insanity and 
mixed insanity, delusion of persecution, moral insanity, and 
the dementia following these different forms of insanity. 

II. Epileptic insanity, or insanity with epilepsy, whether 
the convulsive affection has preceded the insanity and has 
seemed to have been the cause ; or whether, on the contrary, 
it has appeared during the course of the mental disease only 
as a symptom or a complication. 

III. Paralytic Insanity. — This commission regards the 
disease called general paralysis of the insane as a distinct 
morbid entity, and not at all as a complication, a termina- 
tion of insanity. It proposes, then, to comprehend under 
the name of paralytic insane all the insane who show in any 
degree whatever the characteristic symptoms of this disease. 

IV. Senile dementia, which we would define as the slow 
and progressive enfeeblement of the intellectual and moral 
faculties consequent upon old age. 

V. Organic dementia ; a term by which the commission 
means to designate a disease which is neither the dementia 
consequent upon insanity or epilepsy, nor paralytic demen- 
tia, nor senile dementia, but that which is consequent upon 
organic lesion of the brain, nearly always local, and which 
presents, as an almost constant symptom, hemiplegic occur- 
rences more or less prolonged. 



338 DISEASES OF THE BRAIN. 

VI. Idiocy, characterized by the absence or arrest of 
development of the intellectual and moral faculties. Imbe- 
cility and weakness of mind constitute hereof two degrees 
or varieties. 

VII. Cretinism, characterized by a lesion of the intel- 
lectual faculties more or less analogous to that observed in 
idiocy, but with which is uniformly associated a character- 
istic vicious conformation of the body, an arrest of the de- 
velopment of the entirety of the organism. Outside of 
these typical forms there are others, such as — 

1. Delirium tremens. 

2. Delirium of acute diseases ; traumatic delirium. 

3. Simple epilepsy. 

My own classification is much simpler than most that 
have been proposed, and is based entirely on the division 
of mind given. In part it has been brought forward by 
other authors, though with different explanations of the 
terms employed. 

I. Perceptional insanity, characterized by the tendency 
to the formation of erroneous perception either from false 
impressions of real objects (illusions), or from no external 
excitation whatever (hallucinations). 

II. Intellectual insanity, characterized by the existence 
of delusions. 

III. Emotional insanity, characterized by the uncon- 
trolled or imperfectly-controlled predominance of one or 
more of the emotions. 

IY. Volitional insanity, in which there is an inability 
to exert the full will-power either affirmatively or nega- 
tively. 

Y. Mania, characterized by the union of two or all four 
of these forms in the same individual. 

YI. General paralysis, a peculiar form of insanity, at- 
tended with progressively-advancing loss of mental and mo- 
tor power. 

YII. Idiocy and dementia : the first due to the fact that 



INSANITY. 339 

there are original structural defects in the brain ; the sec- 
ond resulting from the supervention of organic changes in 
a brain originally of normal power. 

In a work like the present, embracing the diseases of the 
whole nervous system, it is, of course, impossible to consider 
at full length the very interesting subject of insanity. I 
shall endeavor, however, to give certain prominent features, 
referring the reader, for more complete information, to the 
monographs treating specifically of diseases of the mind. 1 

But, before proceeding to describe the several types men- 
tioned, there are some important symptoms of mental disor- 
der, the character and import of which must be clearly un- 
derstood. These are illusion, hallucination, delusion, inco- 
herence, and delirium. 

Illusion. — An illusion is a false perception of a real sen- 
sorial impression. Thus a person seeing a ball roll over the 
floor, and imagining it to be a mouse, has an illusion of the 
sense of sight ; another, hearing the pattering of the rain on, 
the roof, and perceiving in this sound the voice of some one 
calling him, has an illusion of the sense of hearing ; another, 
having some bitter substance placed upon his tongue, and 
forming the perception of a sweet flavor, has an illusion of 
the sense of taste ; and so on as regards the other senses. 
In all such cases there is a material basis for the perception, 
but this latter is not in exact relation with the former. 

Illusions are not always indicative of cerebral disorder ; 
indeed, they are very common with all of us under certain 
circumstances. It is, perhaps, never the case that the per- 
ception is precisely in accordance with the real properties 
of the substance making the sensorial impression. We never 
see, hear, taste, smell, or feel things exactly as they are. 
This imperfection may be due to surrounding circumstances 
not being favorable. Insufficient light may thus make our 

1 Xo work is better calculated to give philosophical views of the subject of 
insanity than the treatise of Dr. Maudsley, on the " Physiology and Pathology 
of the Mind." His little work on the " Body and Mind " is also admirable. 



340 DISEASES OF THE BRAIN. 

vision imperfect ; loud noises may render us incapable of ap- 
preciating gentle sounds. A strongly-sapid substance pre- 
viously rubbed over the tongue and fauces prevents our dis- 
tinguishing delicate flavors ; a powerful odor may make 
such an impression on the schneiderian membrane that 
other odors for a long time smell like it, and exposure to 
very cold weather interferes markedly with the discriminat- 
ing power of the sense of touch. 

Imperfect perceptions are often formed in consequence 
of the perceptive ganglia being otherwise occupied. Thus, 
if we are looking intently at some object of interest, we are 
apt not to attend to the sounds which reach our ears, and 
consequently no clear perception of them is formed. 

Illusions of all the senses, but especially of sight and 
hearing, are met with in insanity, and particularly in those 
acute forms characterized by the presence of delirium. 

Hallucination. — An hallucination is a false perception 
without any material basis, and is centric in its origin. It 
is more, therefore, than an erroneous interpretation of a real 
object, for it is entirely formed by the mind. An individ- 
ual, who, on looking at a blank wall, perceives it to be cov- 
ered with pictures, has an hallucination ; another, who, when 
no sounds reach his ear, hears voices whispering to him, also 
suffers frcm an hallucination, and such false perceptions 
may be created as regards all kinds of sensorial excitations. 
The organs of the senses, in fact, are not necessary to the 
existence of hallucinations. Thus, if the eyes be closed, 
images may still be seen; if the hearing be lost, voices may 
still be heard, and the reason for this is found in the fact 
that the erroneous perception constituting the hallucination 
is formed in that part of the brain which ordinarily requires 
the excitation of a sensorial impression for its functionation. 
Hallucinations are always evidence of cerebral derangement, 
and are common phenomena of insanity. They may be ex- 
cited by emotions of various kinds, by which the character 
or quantity of the bleod circulating in the brain is changed, 



INSANITY. 341 

by intellectual exertion, by certain drugs, and many other 
factors to be presently more fully considered. 

Delusion. — Illusions and hallucinations may exist, and 
the individual be perfectly sensible that they are not reali- 
ties. In such cases the intellect is not involved. But, if he 
accepts his false perceptions as facts, his intellect partici- 
pates, and he has delusions. A delusion is, therefore, a false 
belief. It may be based upon an illusion or an hallucination, 
may result from false reasoning in regard to real occurrences, 
or be evolved out of the intellect spontaneously by the result 
of imperfect information, or of an inability to weigh evidence 
or to discriminate between the true and the false. Delu- 
sions are not a test of insanity, as most lawyers and many 
physicians believe. If they were, one-half the world would 
be trying to put the other half in lunatic asylums! They 
may be present without coexistent insanity, and many cases 
run their course without them. 

To be indicative of insanity, a delusion must be contrary 
to the customary mode of thought of the individual. Thus 
a believer in spiritualism is not necessarily insane because 
he sees and converses with the spirit of Benjamin Franklin, 
for it is a part of his mentality to believe in the existence of 
spirits and in the possibility of evoking them so as to see 
them and talk with them. But, if a non-believer in spirit- 
ualism should imagine that he was in the habit of seeing 
Franklin's spirit and of conversing with it, it would be good 
evidence of his insanity. And further, though the spirit- 
ualist might think he had interviews with Franklin, and 
still be sane, yet if he believe, without foundation and con- 
trary to evidence, that his brother had tried to poison him, 
he would have a delusion sufficient to indicate his insanity. 

At a former period of the world's history, a belief in the 
possibility of seeing devils and demons of various kinds, and 
of suffering from their torments, was commonly entertained. 
Indeed, it is religiously held now by a great many otherwise 
sensible people. Such a belief is, according to my mode of 



342 DISEASES OF THE BRAIN. 

thought, a delusion, and probably nine-tenths of those who 
read this treatise will agree with me in so regarding it. But 
it certainly would not be safe to consider every one holding 
such a creed as insane. A like reasoning applies to the 
holders of every other form of belief not in accordance with 
our own. A delusion, to be indicative of insanity, must be 
such a belief as would not be entertained in the ordinary 
normal condition of the individual, must have been formed 
without such evidence as would have been necessary to con- 
vince in health, and must be held against such positive testi- 
mony as would have in health sufficed to eradicate it. 

Insanity may exist without delusions at any time being 
present. Thus there may be emotional insanity, the main 
feature of which consists of mental depression with an un- 
reasoning tendency to suicide ; or there may be volitional in- 
sanity, characterized by an inability to refrain from setting 
fire to neighbors' houses, or from committing homicide. 

Incoherence. — A person is said to be incoherent when 
the words he utters are without proper relation to each 
other, or when his language is not in accordance with his 
ideas. As an example of incoherence, I cite the following 
letter which I received a few days since from a patient : 

" In the Neck, January 7, 1871. 

" Dear Sir : I said he was in my own conscience that 
the book was confined I quote the long time with eccentri- 
city in the common way. This is in memory to my upshot 
which was incorrect at the final oblivion. Dogs and money 
consistency with foundlings without ante bellum which was 
in statu quo. 

" This is passive in contiguity with the works met in 
the creation of existence. 

" Very commingle 

" in good faith 

« J. S. W ." 

This exhibits an extreme case, as there is not an idea to 



INSANITY. 343 

be obtained from the language used. Such instances are, 
however, common enough. 

Incoherence is a prominent feature of delirium, and is 
sometimes met with in the chronic insane. It is directly 
due either to the impossibility of keeping the attention suf- 
ficiently long on one idea for its full consideration, or to a 
like difficulty in coordinating those parts of the brain which 
are concerned in the formation and expression of thoughts. 

Delirium. — Delirium is that condition in which there 
are illusions, hallucinations, delusions, and incoherence, to- 
gether with a general excess of motility, an inability to 
sleep, and acceleration of pulse. In acute delirium these 
phenomena are well marked ; in the low and chronic forms 
they are less strongly indicated. Sometimes one or the 
other of these elements notably predominates. Delirium is 
present in the early stage of acute mania, and may exist as 
an accompaniment of certain diseases of the brain which do 
not ordinarily cause insanity, such as cerebral congestion or 
anaemia. It is also common in fevers and in several other 
disorders of the system. 

I. — Perceptional Insanity. 

In uncomplicated perceptional insanity, those parts of 
the brain only are disordered which are concerned in the for- 
mation of perceptions. It constitutes the primary form of 
mental aberration, and of itself is not of such a character as 
to lessen the responsibility of the individual, or to warrant 
any interference with his rights. It consists entirely in 
false perceptions ; and if the intellect is for a moment de- 
ceived, the error is immediately corrected. As already 
stated, these are either illusions or hallucinations. In some 
cases these erroneous perceptions may coexist in the same 
individual. They may be related to all the senses, but are 
especially common as regards sight and hearing. 

Illusions, as already mentioned, are not necessarily due 
to any centric difficulty, though such an origin is common. 



344 DISEASES OF THE BRAIN. 

Thus, it is an illusion if a person on looking at an object sees 
two images. This result is due to some cause destroying 
the parallelism of the visual axes, and may be produced 
by a tumor of the orbit or by paralysis of one or the other 
of the ocular muscles. Even in such a case, if the paralysis 
were due to central lesion, the higher ganglia of the brain 
might escape implication. Illusions are often excited by 
emotional disturbance, and are then probably directly due 
to some disturbance of the cerebral circulation. The false 
perceptions called hallucinations are of more importance 
than illusions, in the symptomatology of insanity in general. 
In the purely perceptional form of mental aberration they 
are also exceedingly interesting, and are very often trouble- 
some symptoms. Thus, a gentleman, who had overworked 
himself in financial business, was subject to hallucinations of 
hearing, which, however, did not in the least impose on his 
intellect. As he walked through the streets to his place of 
business, he heard a voice continually whispering to him, 
" Take care — take care ! " So strong was the impression 
made, that he often involuntarily turned round to see who 
was speaking to him. In another case, a gentleman saw im- 
ages of various kinds as soon as his head touched the pil- 
low, though they were never present when he was standing 
or sitting. 

The case of Mcolai, the German bookseller of the last 
century, is well known as a remarkable example, and others 
are afforded in the cases of Jerome Cardan, Pascal, and 
many other noted personages. 

Like illusions, 1 the immediate cause of hallucinations is 
generally derangement of the cerebral circulation, either as 
regards quantity or quality. 

As is well known, they are frequently produced by alco- 

1 For a fuller account of the subjects of illusions and hallucinations, the 
reader is referred to the author's works on Sleep and its Derangements : J. B. 
Lippincott & Co., Philadelphia ; and the Physics and Physiology of Spiritualism : 
D. Appleton & Co., New York. 



INSANITY. 34-5 

holic liquors, opium, belladonna, Indian hemp, and other 
drugs. They may also result from mental exertion and 
emotional disturbance, from an overloaded stomach, or may 
occur in the course of various diseases, especially those of a 
febrile or exhausting character. 

Perceptional insanity may make its appearance sudden- 
ly, the first evidence of its presence being the illusion or 
hallucination. Usually, however, there are prodromata in- 
dicating cerebral derangement. These are pain in the head, 
irritability of temper, suffusion of the eyes, noises in the 
ears, a general restlessness, and some febrile excitement. 
The skin is generally dry, the mouth parched, the bowels 
costive, and the urine high colored and scanty. If not ar- 
rested, it may pass into one or the other of the following 
types of mental aberration. 

II. — Intellectual Insanity. 

The essential feature of intellectual insanity is delusion. 
It may be developed suddenly, or, as is generally the case, 
preceded by evidences of cerebral disorder, which, though 
at the time of their occurrence not attracting particular at- 
tention, are called to mind by the observers after the disease 
has become fully developed. 

In the first stages of intellectual insanity it is not often 
that the delusions are fixed, and they may succeed each 
other with such rapidity that the patient resembles one af- 
fected with mania. They may be based on illusions or hal- 
lucinations, or may arise from the reasoning of the patient 
from purely imaginary premises not connected with the 
senses. Sometimes they are spontaneous, and at others 
they appear to come from dreams. 

Thus, a gentleman, who had for several days been singu- 
lar in his behaviora, woke in the night and imagined that he 
saw his wife standing by his bedside with a phial of prussic 
acid which she was about to empty into his mouth. The 
hallucination took such strong hold of him that he went 



346 DISEASES OF THE BKAIN. 

into the adjoining room, where his wife slept, to see if she 
were there or not, and, though he fonnd her sleeping quietly, 
he awoke her, and accused her of having attempted to poi- 
son him. No amount of argument or persuasion could eradi- 
cate the false belief from his mind. 

Another for several days had been spending money very 
freely in articles of little or no use to him, when one morn- 
ing he announced to his family that for several days he had 
been thinking a great mistake had been committed in his 
conception, and that his soul had got into the wrong body. 
He was therefore convinced that he was not the man he 
should have been, and hence he had done a great many 
things which were altogether repugnant to his physical 
senses. So long as the antagonism continued between his 
mind and his body, there was no hope of any happiness for 
him in this world. In this case there had never been any 
hallucination or illusions of any of the senses. The delusion 
was therefore entirely the res.ult of the patient's own per- 
verted thoughts. 

When rapidly following each other, delusions are clearly 
spontaneous — are not the result of any series of thoughts, 
but come on the spur of the moment and upon very slight 
suggestions. As they are readily formed, they are not fixed 
in character. A lady, for instance, after receiving some 
very sorrowful intelligence relative to her husband, im- 
agined that she had lost her eyesight. For a few hours she 
remained with her eyes shut, alleging that there were two 
deep cavities behind the lids. Suddenly she opened them, 
said she saw perfectly well, but that the top of her head had 
been cut off, and this was almost immediately changed to 
the belief that she was perishing with cold, and so on, no 
one delusion lasting longer than a few minutes. In many 
cases like this the erroneous beliefs are excited by sensations 
in various parts of the body, but this was not so in the pres- 
ent instance. 

The connection between dreams and insanity is very 



INSANITY. 347 

close. Most of us have at times had such vivid dreams that 
they have been removed from our minds with difficulty. 
There appears to be no doubt that many of the delusions of 
the insane have dreams for their cause. 

The delusions of the insane are, in the great majority 
of cases, connected more or less directly with themselves. 
Thus a person believes that his leg is made of glass, that his 
head is reversed on his shoulders, that he is some great per- 
sonage, that a large fortune has been left to him, or that 
some misfortune has deprived him of his property or his 
friends. He will often reason logically and forcibly from 
the premises he has assumed, and will give no evidence of 
insanity outside of his delusion. Such cases are embraced 
under the term of reasoning mania, and the skill and acu- 
men exhibited by persons thus affected are often surprising. 
"When it is important, in their estimation, for them to con- 
ceal their delusions, they will often do so for a long time, 
and stratagems of various kinds are necessary to their 
speedy detection. Sooner or later, however, the delusion 
comes out. 

The designation monomania can properly be applied to 
many of the cases of intellectual insanity. In the uncom- 
plicated form of the disease it is rare, after it is fully estab- 
lished, that more than a single object, or a small class. of 
objects, are the subjects of the delusions. 

The delusions of the insane may be comprehended under 
two categories — those which are of a pleasant or exalted 
character, and those which are unpleasant or morbid. 
These usually leave their impress on the countenance of the 
patient, and his actions and manner are in accordance with 
them. 

It would be strange if this were not the case. The only 
guide which man has for his actions is his reason. He 
weighs arguments and motives, and determines according 
to the bearing which they may have on his mental processes. 
A delusion is, in many cases, simply a false premiss ; the 



348 DISEASES OF THE BRAIN. 

conclusions which the individual draws from it are entirely 
logical. Taking, for instance, the case of the gentleman 
who had imbibed the idea that his wife had attempted to 
poison him ; and, admitting that he was correct in this no- 
tion, his subsequent conduct — his denunciations, his refusal 
to live with her, his efforts to have her imprisoned, etc. — is 
perfectly reasonable. The line of conduct was such as most 
men would have pursued under like circumstances. In such 
cases, therefore, there is no fault in the intellectual processes 
after the first step is taken. It is this first step which con- 
stitutes the disease — it is the delusion which enslaves the 
mind. 

Intellectual insanity is often uncomplicated by any other 
form of mental derangement. There are no illusions, no 
hallucinations, no overpowering influence of the emotions, 
and no loss of control over the will. Even when the de- 
lusion is of such a character as apparently to be connected 
with some one of the senses, and thus to be based upon a 
false perception, full inquiry will often show that there is 
no error of the sensorial processes, centric or eccentric. 
Thus, a lady under my care had the delusion that she had 
lost her palate, as she called it. I held a mirror to her face, 
and, while she opened her mouth, I pointed out to her that 
all the parts were present. " Yes," she replied, " I see all 
that ; the form is there, I know very well, but the substance 
is gone ; " and no arguments could convince her to the con- 
trary. A gentleman conceived that his right hand was 
made of glass, and therefore, to prevent its being broken, he 
kept it carefully enclosed in a stout case made to fit it 
accurately. On my calling his attention to the physical 
qualities of his hand, and pointing out how they differed 
from those of glass, he said: "I once thought just as you do. 
My brain was then incapable of appreciating minute differ- 
ences as well as it can now ; and, though I confess that my 
senses still convey to me the idea that my hand is like other 
people's, yet I know the conception is erroneous, and I cor- 



INSANITY. 349 

rect it at once by my reason. My hand looks like flesh and 
blood, but it is glass for all that. Nothing is more calcu- 
lated to deceive than the senses." 

Persons affected with uncomplicated intellectual insanity 
may go through the world without giving any considerable 
evidence of mental derangement, unless the subject of their 
delusions be touched upon. Still, there is no telling to 
what extremes a delusion may carry its subject. Like a 
sane idea, it may extend further with each day of life. A 
person, for instance, imagines that he is the Emperor of 
Eussia. At first he does not comprehend the full impor- 
tance of his supposed position, and, if of moderate reasoning 
power, possessing deficient information, and naturally of a 
quiet disposition, he may never go further than dressing 
himself in some tawdry finery, and strutting pompously 
through the wards of the hospital. But, under other cir- 
cumstances, he reflects upon the greatness of his station, and 
thus, from time to time, he conceives new ideas of his pow- 
ers and importance, and may thus become a very trouble- 
some patient. He comes to believe, perhaps, that he has 
the power of life and death, and may attempt to exercise 
his imaginary prerogative. 

Delusions in regard to relatives and friends are very 
common, and hence the conduct of the person entertaining 
them is changed as it relates to the objects of his erroneous 
ideas. It is a usual thing, therefore, for such an insane per- 
son to disinherit those who would naturally be heirs of his 
property. This point is of importance in its medico-legal 
relations. 

Delusions may be of such a character as to affect the 
emotions secondarily. A very common delusion is that of 
having committed the unpardonable sin, and accordingly the 
patient suffers great emotional disturbance. This influence 
upon the emotions is perfectly natural and logical, for, if 
the person really had committed a sin for which there is no 
hope of pardon, and had thus incurred the punishment of 



350 



DISEASES OF THE BRAIN. 



eternal damnation, it would be strange if the emotions of 
sorrow and despair were not excited into activity. Such 
cases, however, are not to be embraced under the head of 
emotional insanity ; and, though at first sight they may ap- 
pear to be of that type, inquiry will reveal the fact of the 
preexistence of the delusion. 

Intellectual insanity is often the sequence of an attack 
of acute mania, which form of mental aberration will be 
presently considered. 

I subjoin the accompanying portrait, engraved from a 



Fig. 12. 




photograph, of a typical case of intellectual insanity. The 
patient was, for many years, an inmate of the New York 



INSANITY. 351 

City Lunatic Asylum on Blackwell's Island. Her delusion 
was, that she was the wife of the late President Buchanan. 
She assumed his name, and was exceedingly tenacious of 
her rights and dignities. All visitors were received by her 
with as much formality as though she were the real mistress 
of the White House. It will be seen, upon examination, 
that there is no trace of emotional disturbance to be per- 
ceived in her countenance. The expression of her face is 
intelligent and shrewd, and she might have walked Broad- 
way every day of her life without exhibiting as much evi- 
dence of insanity as many of those who perambulate that 
thoroughfare and are considered perfectly sane. 

III. — Emotional Insanity. 

The emotions are at all times difficult to control, but 
they may acquire such undue prominence as to dominate 
over the intellect and the will, and assume the entire mas- 
tery of the actions in one or more respects. This effect may 
be produced suddenly, from the action of some cause capable 
of disturbing the normal balance which exists among the 
several parts of the mind, or it may result from influences 
which act slowly but with gradually-increasing effect. In 
either case there is not necessarily either delusion or error 
of judgment, but it very generally happens that the intel- 
lect sooner or later becomes involved. 

Emotional insanity may be produced without there being 
any discoverable cause, and without the patient being able 
to allege a motive. 

Some emotions are more frequently disordered than 
others. Those of a sorrowful character are preeminent in 
this respect, and, when they are affected, the type of insanity 
called melancholia is the result. This may be either acute 
or chronic in its course. The first is rarely uncomplicated, 
and hence will be more properly considered under the head 
of mania. 

Homicide, suicide, and other crimes, may be the result 



352 DISEASES OF THE BRAIN. 

of emotional disturbance as well as of intellectual insanity. 
The most common of these is undoubtedly suicide, the in- 
dividual committing self-destruction in order to escape from 
the depressing influences which act upon him. It more fre- 
quently happens, however, that the emotions are disordered 
through the morbid operations of the intellect. A person, 
for instance, to cite the example previously given, imbibes 
the delusion that he has committed the unpardonable sin, or 
that God has deserted him, and, in consequence, passes into 
a condition of settled melancholy, during which he may at- 
tempt self-destruction to escape from his harrowing thoughts, 
or commit a homicide, in order that the same end may be ac- 
complished by his being hanged for murder. Other emotions 
may of course be excited into morbid activity by derange- 
ment of the intellect. Delusional jealousy, anger, hatred, 
or love, may thus urge their unfortunate victim to the per- 
petration of crime, plunge him into a depth of unhappiness 
from which there is no escape, or lift him into an ecstasy of 
bliss far exceeding that derivable from the realization of all 
his wishes. 

Under the head of moral insanity, Dr. Prichard, several 
years ago, described a form of mental derangement which 
embraced several species which are now more properly 
placed under other heads. Several of these are clearly emo- 
tional in character, and most of them relate to altered modes 
of feeling or of the affective faculties, and therefore, in the 
largest sense of the word, may also be called emotional. 
Careful and thorough inquiry will, however, often show that 
the primary difficulty is one of defect, and not of aberration 
or exaggeration, and that, therefore, these instances of defi- 
cient moral sense, leading the subjects to the perpetration 
of crimes of various kinds, should be classed under the head 
of imbecility. 

Many cases of what are called temporary insanity, mania 
ephemera, transitory mania, and morbid impulse, are really 
instances of emotional insanity. That such a condition ex- 



INSANITY. 353 

ists there can be no doubt, and it is important, both as re- 
gards the subject and society, to be able to recognize or to 
disprove its presence. 1 A few words, therefore, on this 
point, will not be out of place. 

The state with which transitory emotional insanity is most 
apt to be confounded is that which has been designated heat 
of passion. Passion is emotional activity. It refers to that 
mode of the mind in which certain impressions or emotions 
are felt, and which is accompanied by a tendency or impulse, 
often irresistible, to act in accordance with these impres- 
sions or emotions irrespective of the intellect. An act per- 
formed in the heat of passion is one prompted by an emo- 
tion which for the moment controls the will, the intellect 
not being called into action. It is an act, therefore, per- 
formed without reflection. The passions are, to a certain 
extent, under the control of the will, and this power of 
checking their manifestations is capable of being greatly in- 
creased by self-discipline. Some persons hold their passions 
in entire subjugation, others are led away by very slight 
emotional disturbances. The law recognizes the natural 
weakness of man in this respect, and wisely discriminates 
between acts done after due reflection and those committed 
in the midst of passional excitement. 

The acts performed during temporary emotional in- 
sanity, in their more obvious aspects, and when viewed iso- 
latedly, resemble those done in the heat of passion. But 
they are so only as regards the acts themselves. Thus a per- 
son, entering a room at the very moment when one man was 
in the act of shooting another, would be unable to tell 
whether the homicide was done in the heat of passion, or 
under the influence of an attack of temporary insanity ; he 
would be equally unable to say whether it was committed 
with malice aforethought or in self-defence. The act, there- 

1 The best monograph on temporary insanity with which I am acquainted is 
that of Krafft-Ebing, Die Lehre von der Mania Transitoria, fur Aerate und Ju- 
risten dargestelt. Erlangen, 1865. 
23 



354 DISEASES OF THE BRAIN. 

fore, by itself, can teach us nothing. We must look to the 
attending circumstances, and to the antecedents of the per- 
petrator, for the facts which are to enlighten us as to the 
state of mind of the actor. Now, the conditions of tempo- 
rary emotional insanity are so well marked that the act 
which indicates the height of the paroxysm may almost be 
disregarded, for it is always preceded by symptoms of men- 
tal aberration, while acts done in the heat of passion are not 
thus foreshadowed. 

And, as regards the subsequent state of the individual, 
the distinction is equally apparent. The one who has com- 
mitted a criminal act in the heat of passion soon subsides 
to his ordinary condition of equanimity, and generally be- 
gins to think of his safety. The one who has perpetrated a 
similar act during an attack of temporary emotional in- 
sanity never thinks of escape, nor even avoids publicity. 
He may even boast of his conduct, or deliver himself into the 
hands of the law. What is, however, of greater importance 
is the fact that, though he may subside into a condition of 
comparative sanity, the evidences of disease are still present, 
and remain in him for days, weeks, or even months and 
years. These symptoms are generally those of cerebral con- 
gestion, to which attention has already been directed. 

In heat of passion, the act follows immediately on the 
excitation of which it is the logical sequence. In temporary 
insanity, the act is the culmination of a series of disordered 
physical and mental manifestations, and may or may not be 
in relation with the emotional cause. The distinction is, 
therefore, clear and precise. The case of Henriette Cornier, 
so fully detailed by Georget, 1 is a striking instance of the 
action of emotional disturbance and morbid impulse. This 
woman was twenty-seven years of age, was of a joyous dis- 
position and gentle in her ways, and particularly fond of 
young children. 

In June, 1825, a notable change ensued in her ; she be- 

1 Discussion Medico-Legale sur le Folie, ou Alienation Mentale, Paris, 1826. 



INSANITY. 355 

came sedate, seldom laughed, sighed often, was taciturn, and 
neglectful of her work. She was accordingly discharged 
from her service as domestic, and returned to her friends. 
She soon afterward made an attempt at suicide by throwing 
herself from the parapet of a bridge, but was prevented. 

She then entered the service of a Madame Fournier, still 
being disposed to melancholy, notwithstanding all efforts 
made to restore her. 

On the 4th of November, her mistress went out, leav- 
ing Henriette at her work, and directing her to go to a shop 
kept by a woman named Belon, and get some cheese. This 
woman had a very beautiful little daughter not two years 
old, for whom Henriette had always manifested a great lik- 
ing. On this occasion she fondled the child as usual, and 
persuaded her mother to let her take it out to walk. Hen- 
riette took the child to Madame Founder's house, and, go- 
ing first to the kitchen, obtained a large knife, with which, 
and the child, she went to her own room. On the stair- 
case she met the porteress, and, before her, embraced with 
every evidence of love the little child she held in her arms. 
Arrived at her own chamber, she laid the infant on its back 
on the bed, and, seizing its head with one hand, she with the 
other drew the knife rapidly across the neck and severed 
the head from the body before her victim could utter a cry. 
Before, during, and after this crime, she had, as she de- 
clared, no emotion or feeling of horror. On the contrary, 
she was calm, collected, felt neither pleasure nor sorrow, but 
apparently acted mechanically. 

Two hours afterward the mother came for her child ; 
Henriette stood at the door. " Your child is dead," she ex- 
claimed, and then, entering the room, seized the head of the 
murdered infant and threw it into the street. 

On the arrival of the officers, she was found sitting in 
the room with the dead body, gazing at it, her hands covered 
with blood and the knife near her. She did not deny her 
crime, and exhibited neither penitence nor remorse. " I in- 



356 



DISEASES OF THE BRAIN. 



tended to kill it," she said, and, on being further interro- 
gated, declared that she had no particular motive ; that she 
had experienced the inclination, and she was destined to 
perpetrate the act. 

She was suspected of insanity, and was examined by a 
commission consisting of Adelon, Esquirol, andLeveille, who 
reported that they were unable to determine whether she 
was sane or not. This report not being satisfactory, a sec- 
ond examination was ordered, but still no definite opinion 
could be obtained from the commission. She was tried and 
found guilty, very illogically, of voluntary but unpremedi- 
tated homicide, and was sentenced to hard labor for life. 

Fig. 13. 




The above likeness (Fig. 13) is that ot a woman affected 



INSANITY. 357 

with pure emotional insanity, of a depressing character, but 
without delusions of any kind. She could assign no cause 
for the intense melancholy with which she was affected, and 
which caused her to pass the greater part of the day crying 
and wringing her hands. She had twice attempted suicide 
before she came under my care, not from any delusion, but 
solely that she might escape from her overpowering emo- 
tions and the mental anguish they caused her. She was 
fully sensible of her situation, knew how groundless was her 
grief, and constantly lamented her inability to control her 
feelings. 

IV. — Volitional Insanity. 

In uncomplicated volitional insanity, there are no delu- 
sions and no emotional disturbance, but solely an inability 
to exert the will in accordance with the intellect. Many 
cases of morbid impulse are instances of volitional insanity, 
in which an idea suddenly flashing across the mind is imme- 
diately carried out by the individual, although his intellect 
and his emotions are strongly exerted against it. Thus, a 
person who previously has not exhibited any very obvious 
symptoms of mental derangement — though careful inquiry 
will invariably show that slight evidences of cerebral disease 
have been present for some days — instantaneously feels a 
morbid impulse to commit a murder or perpetrate some 
other criminal act, and is forced to yield, notwithstanding 
all the efforts he may make. Numerous cases of the kind 
are on record. 

Thus Esquirol ] relates the case of a man thirty-two years 
old, of a nervous temperament and quiet disposition, who 
had been well educated, and who was fond of the fine arts. 
He had suffered from a brain-disorder, but had been several 
months cured. After being in Paris for about two months, 
during which time he led a perfectly regular life, he one 
day entered the Palais de Justice and attacked an advocate 

1 Des Maladies Ment. Paris, 1838, t. i., p. 380. 



358 DISEASES OF THE BRAIN. 

with great fury. The next morning, when seen by Esquirol, 
he was perfectly tranquil and composed, showed no anger 
whatever, and had slept well all night. The same day he 
designed a landscape. He recollected what he had done the 
previous day, and spoke of it with coolness. He declared 
that he had entertained no ill-will against the advocate, had 
never even seen him before, and had no business with hini 
or any other lawyer. He could not understand, he said, 
what had actuated him to make the assault. Subsequently 
he exhibited no indications whatever of being insane. 

Many instances of the so-called moral insanity may prop- 
erly be placed under the head of volitional insanity, for they 
are characterized by an inability to so exert the will as to 
refrain from the perpetration of acts known to be crimes. Of 
such are cases of kleptomania, dipsomania, pyromania, etc. 

The will in insanity is often secondarily affected through 
disturbance originating in the intellect or the emotions, and 
acts are hence performed which give evidence of the exist- 
ence of mental aberration. In mania of all kinds, and es- 
pecially in dementia and general paralysis, there is either a 
loss of volitional control, or an inability to exert the normal 
will-power. 

Y. — Mania. 

In mania the mind is affected in several, generally all 
of its parts. There are illusions, hallucinations, delusions, 
emotional disturbance, and loss of volitional power or control. 
The patient is either morbidly excited or depressed, and is 
often violent in his language and actions. Acute mania is 
the more common species of mental aberration, and in its 
two types of exaltation and depression constitutes the form 
which it is most important for the physician to understand. 
I shall therefore consider them at some length, so far as their 
symptoms and cause are concerned. 

Acute mania with exaltation has its prodromatic stage, 
the symptoms of which are very similar to those which pre- 



INSANITY. 359 

cede an attack of fully-developed cerebral congestion. These 
in the main are pain or fulness in the head, confusion of 
ideas, increased irritability of the mind, and, above all, wake- 
fulness. In addition, there are restlessness of body and a 
singularity of behavior, which strike those thrown into in- 
timate relations with the subject, and cause them to suspect 
that something is wrong with him. 

The character and disposition undergo a change, and 
it is very common for unfounded prejudices to be formed 
against persons formerly highly esteemed. 

Before very long there are illusions and hallucinations. 
At first the patient struggles against them, but eventually 
he accepts them as true, and hence becomes subject to delu- 
sions. These are rarely fixed in the earlier stages, and may 
not be so through the whole course of the disorder. 

With these symptoms there are evidences of derangement 
in other organs besides the brain. Thus, the appetite is less- 
ened, the bowels are torpid, the kidneys fail to eliminate the 
normal quantity of nrine, the heart becomes irregular in its 
action and beats with increased frequency, a certain sign of 
a weak and excited nervous system, and the skin is either 
bathed in perspiration or is dry and hard. 

"With the full development of the disorder the patient be- 
comes incoherent and rambling, showing a great disposition 
to talk, to laugh, and to sing, and indulging in antics of 
various kinds. His delusions mainly have reference to him- 
self: he imagines that he is some great personage, that he 
has suddenly become very rich, or that he has been specially 
singled out for some other piece of good fortune. 

Not unfrequently he is exceedingly troublesome, destroy- 
ing the furniture of his room, tearing his clothes, attacking 
those around him, and making all kinds of attempts to es- 
cape from restraint, but at the same time there is rarely any 
serious effort to do great bodily harm either to himself or 
others. Sometimes, however — and this fact should always 
be born in mind by the attendants — there is a disposition to 



360 DISEASES OF THE BRAIN. 

perpetrate acts of extreme violence, and such a tendency, 
even when not previously manifested, may very suddenly 
be developed. 

Thus, a lady under my care, who had a few days before 
become insane, behaved with propriety, merely making 
continual efforts to get into the street to attend court, where, 
as she believed, she had an important lawsuit. Without 
any warning, however, she went into an adjoining room 
where her infant child was sleeping, and threw it out of the 
window before she could be stopped in her act, exclaiming : 
" Well,, if I can't go out, my baby shall." Fortunately, the 
child fell on a thick grape-vine, and was not injured. 

In another case, a gentleman, whom I saw in consulta- 
tion with my friend the late Prof. George T. Elliot, became 
affected with acute mania of the most hilarious and exalted 
character. While playing on the piano and singing with 
the utmost glee, he expressed a wish for a cracker, and 
went to the dining-room to get one. While apparently look- 
ing for something to eat, he suddenly seized a knife and at- 
tempted to cut his throat. The close proximity of his attend- 
ant alone prevented his inflicting serious injury on himself. 

As a rule, patients with acute mania lose all sense of 
decency, and become exceedingly filthy in their habits and 
obscene in their language and conduct. 

At times such lunatics exhibit a surprising degree of 
cunning, and are able to exercise great control over their 
conduct when they have an end to accomplish. They may 
thus readily deceive the young and inexperienced physician, 
and induce him to forego the idea of putting them under 
permanent restraint, or they may so impose on him as to 
induce him to relax his vigilance, and thus allow of their 
committing some outrageous act. 

It must be remembered that acute mania is not suddenly 
cured, but runs a definite and allotted course. 

It is rare that the memory of the patient suffers to any 
considerable extent in acute mania. The patients are per- 



INSANITY. 361 

fectlj conscious of their surroundings, and are seldom de- 
ceived by the subterfuge so frequently and so unjustifiably 
employed that they are to be taken to a hotel or a country- 
seat when about to depart for an asylum. If the stratagem 
does for the moment impose upon them, they recollect the 
fraud, and will not again repose confidence in those who 
have perpetrated it. 

Their appetites are generally unchanged. If in the 
habit of smoking or drinking, they still want their tobacco 
and their wine, and are usually able to eat a full allowance 
of food. 

After their entrance into the asylum, the main object of 
their lives is to get out again as soon as possible. They often 
recognize their condition, and will call attention to any in- 
dications of improvement they may exhibit. They are not 
for a moment deceived by the delusions of their fellow-luna- 
tics. u Doctor," said a patient to me whom I had sent to a 
lunatic asylum, and was visiting, " this is the best place in 
which to study the infirmities and humbugs of human na- 
ture of which I have any knowledge. Everybody here is 
insane except myself. There is a fellow I used to know be- 
fore he lost his mind, a good, clever fellow he was too, and 
as sharp as a steel trap. Now he is a d — d fool, and thinks 
he takes his breakfast off the top of the capitol every morn- 
ing. And there is a lady holding that bunch of rags to her 
breast and thinking it's a baby. These lunatics are funny, 
very funny, but I've had about enough of them, and would 
like to go somewhere else." At the time this gentleman 
thought he was General Grant, and was going to be inaugu- 
rated President in a few days. 

It is rarely the case that the sleep is regular and sound. 
Often they will lie awake all night, talking of their plans, 
or else will annoy their attendants in every conceivable 
way. Although having usually uncomfortable feelings in 
the head, they rarely suffer from acute pain in that part of 
the body. 



362 



DISEASES OF THE BRAIN. 



The accompanying woodcut represents a case of acute 
mania, with general mental exaltation. ~No one can fail to 
perceive the expression of happiness on the face. 



Fig. 14. 




is^wiift 



11111 



Acute Mania, with Depression. — The acute melancholia 
of many authors is a very terrible form of mental aberration. 
Like that just described, it is generally preceded by prodro- 
mata, which indicate, by their character, the type of insan- 
ity which is about to be developed, but it often appears 
with great suddenness. In the case of a lady now under 
my charge, the first evidence of mental disorder was a vio- 
lent scream, due to the fact that an idea had instantaneously 



INSANITY. 363 

flashed through her mind that she had committed the un- 
pardonable sin, and had consequently lost all hope of saving 
her soul. For several days she continued, with scarcely an 
intermission, to scream, to cry, and to sob, at the same time 
showing the greatest terror from the apprehension that the 
devils were approaching her. Gradually this extreme state 
became less violent, but she still continued to be actuated 
by intense fear, and paced the floor night and day, wringing 
her hands, weeping, and exclaiming, " Lost, lost, lost for- 
ever ! " 

In another case of a lady from the West, the idea sud- 
denly occurred to her that she was about to be killed. She 
screamed, and begged, and prayed, to those around her not 
to allow her to be injured. In the furniture and attendants 
she saw her murderers, and to escape from them made sev- 
eral attempts to throw herself out of the window. Then 
she believed that she was to be poisoned, and refused all 
food with the utmost pertinacity — closing her teeth so firm- 
ly together that it was only by the use of all my strength 
that I could succeed in prying them open. 

Of all the forms of insanity, this is the one in which 
illusions and hallucinations of the senses are most common. 
These are particularly so as regards sight and hearing, and 
do not, as a general thing, refer to the body of the patient — 
although generally in direct relation with his delusion. 

A gentleman, who, within a short period after becoming 
affected with the present variety of insanity, came under 
my care, was controlled by the delusion that he had com- 
mitted so many sins that atonement must be made. He 
had, therefore, several times attempted suicide, and, when I 
entered the room where he was, he was in the act of strug- 
gling with his friends, who were using all their strength to 
prevent him throwing himself out of the window. As soon 
as he saw me, he fell on his knees, held up his hands in the 
attitude of prayer, and mumbled out a few words which 
showed that he took me for a priest, and was asking for in 



364 



DISEASES OF THE BRAIN. 



tercession with the offended Deity. On arriving at the asy- 
lum, to which I recommended him to be immediately sent, he 
went at once to an open coal-lire, and, before any one knew 
what he was about, thrust his hand into the mass of burn- 
ing coals, and succeeded in injuring it terribly. 



Pig. 15. 




In all cases of acute mania with depression, too great 
care cannot be taken to prevent self injury or suicide. It 
must be constantly kept in mind that the idea is a very com- 
mon one with this class of patients, and that frequently they 
manifest great astuteness in concealing it till they are ready 
to make the attempt. 



INSANITY. 



365 



The physician, in general practice, should always urge 
that patients affected with the form of insanity under con- 
sideration should, as soon as possible, be placed in an asy- 
lum, for it is almost impossible to manage them in ordinary 
houses, or with their friends about them. 

The preceding woodcut (Fig. 15) is an admirable like- 
ness, taken from a photograph of a young woman in the 
New York City Lunatic Asylum, suffering from acute ma- 
nia, with depression. Apprehension and terror are plainly 
depicted on her countenance. 

Fig. 16 represents a female inmate of the same asylum, 



Fig. 16. 




366 DISEASES OF THE BRAIN. 

whose history I have not been able to obtain, but whose ex- 
pression of countenance, though less pronounced than that 
of the preceding, is nevertheless sufficiently indicative of the 
existence of mania with depression. 

YI. — General Paralysis. 

The affection now known as general paralysis was first 
described by Delaye, 1 in 1822 ; then by Bayle, 3 in the same 
year; and then, with much more thoroughness and exactness, 
by Calmeil, 3 in 1826. It is a very common form of mental 
derangement, aud, aside from the implication of the mind, 
presents the very striking feature of a gradually-advancing 
paralysis, which derives its name of general from the fact 
that it involves, sooner or later, nearly every muscle of the 
body. This paralysis may show itself at the same time that 
the insanity is manifested ; it may precede the mental de- 
rangement, or it may be subsequent thereto. The latter is 
much the more usual order. 

The mental symptoms differ, in several important re- 
spects, from those which occur in other forms of insanity. 
The first indication of disease is generally an excessive 
anxiety in regard to matters which are really of no great 
importance. Of the cases which have come under my care, 
one was first made apparent by a morbid apprehension on 
the part of the patient that he was not managing some trust- 
funds in the best possible way ; another by the idea that he 
was constantly wounding the feelings of his friends; and 
another was continually changing his mind about the 
most trivial things, and apparently thinking that the world 
watched, with great anxiety, all his movements. 

At first the general mental type is that of depression. 

1 De la Paralysie Generate Incomplete. These de Paris, 1822. 

2 Recherches sur les Maladies Mentales, Paris, 1822 ; and Traite des Mala- 
dies du Cerveau et des Membranes, Paris, 1826. 

3 De la Paralysie Considered chez les Alienes. Recherches faites dans le 
service de feu M. Roger-Collard et de M. Esquirol, Paris, 1826. 



INSANITY. 367 

The emotions are easily excited, and the delusions which 
soon make their appearance are of the melancholic form. 
The idea of propriety in the every-day acts of ' life seems to 
be lost, and the patient will commit all kinds of indecent 
acts without appearing to be aware that he is doing any 
thing unusual. His memory fails rapidly, and his in- 
tellectual vigor declines from the very first. Hence he is 
not able to argue in defence of his delusions, but attacks 
with physical force those who venture to differ with him. 
His acts are in other respects eccentric and absurd. He 
spends money in things which are of no manner of use to 
him, and at the same time refuses to pay his small debts ; 
he harasses in every possible way those who are about him, 
gives them impossible orders, and then abuses them if they 
are not at once obeyed ; he is whimsical at the table, his 
likes and dislikes are changed, and he either eats and 
drinks voraciously, or declares that nothing is cooked to 
suit him, and leaves the table in a rage. Gradually the 
form of his mental aberration changes ; he becomes more 
cheerful, forms all kinds of impossible schemes for suddenly 
acquiring great wealth, and these are quickly abandoned 
for others equally impracticable. Thus delusion after de- 
lusion rapidly succeeds each other, and these, in the great 
majority of cases, relate to the grandeur, the wealth, the 
physical strength, or some other great quality of the patient 
constituting the delire des grandeurs of the French. One 
will tell of his immense palaces built of gold and inlaid 
with precious stones, and in the next breath will descant of 
his great weight or his extreme lightness, or of the number 
of children he has, or of the millions of operas he has com- 
posed. Another urges his great importance in the political 
world, tells us that he has elected all the members of Con- 
gress himself, that he has paid off the national debt, and 
that in consequence he is to be made Emperor of the United 
States, with a salary of a thousand millions a year ; that he 
is going to have a thousand physicians, who are to be clothed 



368 DISEASES OF THE BRAIN. 

in blue-velvet uniforms embroidered in gold and diamonds ; 
that lie has chartered the Great Eastern for a pleasure- trip, 
and engaged ten thousand musicians and a similar number 
of ballet-dancers to go with him. The next day he has for- 
gotten all these fancies, and is off on another series of absurd 
ideas. In no respect is he restrained in the extent of his 
delusions. Impossibilities are not regarded. While scarce- 
ly able to drag one leg after the other, he will brag of his 
great fl eetness of foot, and in the very death-grasp will mutter 
about his extreme strength and endurance. 

The symptoms connected with sensation are equally well 
marked. In the early stage headache is often very severe, 
so much so that, as Westphal * has remarked in his excel- 
lent monograph on the subject of general paralysis, the pa- 
tient often dashes his head against the wall. At other times 
the feeling in the head is that of fulness or tightness, and 
these sensations are often accompanied with vertigo. Neu- 
ralgia in various parts of the body is common, and some of 
my patients have complained of the different degrees of 
numbness, especially in the hands and feet. 

But still more strongly manifested are the disorders of 
motility, due to the progressive paralysis. According to 
my experience, the first sign of loss of power — one which is 
very often observed before any evidence of mental derange- 
ment is perceived — is a slight defect of articulation due to 
paralysis of the lips. At first this is scarcely perceptible ; 
there is merely a little trembling, an action such as that 
seen in persons who are endeavoring to restrain their emo- 
tions, but it is sufficient to give indistinctness to the utter- 
ance of those words which contain labial letters. 

The tongue is the next to be affected. Examination 
shows that there are fibrillary contractions of its muscles, 
and it is moved with less facility. The articulation is slov- 
enly, words are slurred over, and there are both stammering 

1 Ueber den gegenwartigen Standpunct der Kenntnisse von der allgemeinen 
progressiven Paralyse der Irren. Griesinger's Archiv, Heft, i., p. 44. 



INSANITY. 369 

and stuttering. The patient notices these difficulties, and 
in endeavoring to obviate them makes matters worse, by his 
inability to be exact, contrasting strongly with his efforts. 
The paralysis of the tongue gradually becomes more com- 
plete, and at last this organ can only be moved with great 
difficulty. The other facial muscles participate, and a blank, 
somewhat sorrowful, expression is constantly present. The 
voice loses its fulness, and there is difficulty of swallowing. 

The muscles of the eye are also generally involved, pro- 
ducing ptosis from paralysis of the levator palpebrse superi- 
oris diplopia from implication of the internal rectus, and 
contraction of the pupil — all of these effects, except the last, 
being due to difficulty existing at the point of origin, or in 
the course of the third nerve. The pupils are often nnequal, 
and Austin * declares with all seriousness that contraction 
of the right pupil is associated with melancholic delusions, 
and contraction of the left pupil with elation. Further in- 
vestigation has not confirmed this theory. The gait of pa- 
tients affected with general paralysis is very peculiar, and 
is of two distinct kinds. In the one it is similar to that of 
a person suffering from sclerosis of the posterior columns of 
the spinal cord (locomotor ataxia). The feet are lifted high, 
and are thrown down with a good deal of force, the heel 
striking the ground first. As Westphal remarks, patients 
with this gait cannot stand with the eyes shut and the feet 
close together. 

In the other kind the feet are scarcely lifted from the 
ground, but are shuffled over it, and the action is somewhat 
like that of a person attempting to balance himself on a 
tight-rope. Patients with this gait can without difficulty 
stand with the eyes shut. 

As regards the upper extremities, the fingers lose their 
strength and delicate coordinating power. The handwrit- 
ing is shaky, and there is awkwardness in buttoning the 

1 A Practical Account of General Paralysis, its Mental and Physical Symp. 
toms, Statistics, Causes, Seat, and Treatment, London, 1859, p. 31, et seq. 

24 



370 DISEASES OF THE BRAIN. 

clothing. The grip of the hand is still strong, but there is 
an impossibility, as shown by the dynamograph, of main- 
taining a continuous muscular contraction for even a few 
seconds. The following is one of the tracings made by a 
patient affected with the disease under consideration : 

Fig. 17. 




In analyzing this tracing, we see that it is not from 
feebleness of the muscles that the line is descending, for 
there are spasmodic elevations which show considerable 
force. It proves, however, that, no matter at what point 
the pencil is placed, the patient cannot keep it there. 

The senses, with the exception of sight, do not often be- 
come materially affected. Atrophy of the optic nerve causes 
amaurosis or amblyopia. Ophthalmoscopic examination will 
very generally detect this condition of the papilla at a very 
early stage of the disease, together with retinal and choroidal 
anaemia. 

Convulsive seizures occur, and these are generally epi- 
leptiform in character, though occasionally they are of the 
nature of apoplexy. They vary greatly in character, some- 
times resembling the petit mat of epilepsy ; at others, char- 
acterized by strong convulsive movements or coma. Be- 
sides these, there are attacks of complete paralysis of certain 
muscles, or groups of muscles, which, however, rarely leave 
any permanent effects, the usual degree of power being re- 
gained in a few days. 



INSANITY. 371 

The course of general paralysis is often marked by peri- 
ods of great improvement, and the patient's friends imagine 
that he is certainly recovering. The symptoms, mental and 
physical, all abate in violence, and may even disappear to 
such an extent as not to be evident to general observers. 
But the physician must not be deceived, for the ameliora- 
tion is merely temporary, and sooner or later the disease re- 
gains its former ascendency. At no time, even during the 
height of the remission, is the mind of the patient in such a 
condition as to admit of any considerable intellectual exer- 
tion. There may be an absence of delusions, but the men- 
tal weakness still exists. 

Progressively this decline in the force of the mind be- 
comes more strongly marked, until at last a condition of ex- 
treme dementia is reached. Simultaneously the physical 
power diminishes, until finally the patient, unable to walk, to 
stand, or even to sit, is confined to the bed for the rest of his 
existence. Bed-sores form, and deglutition becomes more 
and more difficult. From this cause, the food may become 
impacted in the fauces, and thus death produced by inter- 
ruption to the respiratory process ; or the food may enter 
the larynx. The sensibility of the lining membrane of the 
cheeks and fauces is notably diminished, and hence the pa- 
tient, in eating, goes on filling his mouth, not knowing that 
he is doing so. When he at last attempts to swallow, the 
mass of food is greater than can pass down the oesophagus, 
and, unless some one is near to assist him, he chokes to 
death. 

Death may otherwise take place from a gradual cessa- 
tion of the respiratory process, or from sheer exhaustion. 

The duration of general paralysis is variable. Some- 
times death results in a few months, and at others it may be 
deferred for five or six years. The average period is about 
three years. G-eneral paralysis is not likely to be confound- 
ed with any other affection than chronic alcoholic intoxica- 
tion, from which the history of the case and its general 



372 



DISEASES OF THE BRAIN. 



progress will suffice to distinguish it. "With lead paralysis 
it has scarcely any features in common. 

General paralysis is almost invariably fatal. A few cases 
of recovery have been reported, but there is room for doubt- 
ing that most of them were actual cases of the disease, and 
the others were probably, as Griesinger suggests, instances 
in which the remission was long. A complete recovery in 

Fig. 18. 




which the patient has been able to resume his ordinary oc- 
cupation, and to exert his natural mental and physical pow- 
ers, has certainly not come under my notice. At the same 
time, recognizing the skill brought to bear upon modern 
medical science, I do not despair of eventually being able to 
give a more hopeful statement. That the life of the patient 



INSANITY. 



373 



can be prolonged and his condition improved by judicious 
management I am very sure. 

The preceding cut (Fig. 18), which I take from Tuke 
and Bucknill's " Manual of Psychological Medicine," gives 
a more typical representation of the face of a patient suffer- 
ing from general paralysis than any I have been able to 
find elsewhere. 

VI. — Idiocy and Dementia. 
The subject of idiocy does not come within the scope of 

Fig. 19. 




the present work, and I merely mention it as an element in 
the classification I have proposed. The treatment of those 



374 DISEASES OF THE BRAIN. 

so unfortunate as to be originally weak-minded, is a particu- 
lar branch of medical science which requires special train- 
ing, and which could not be sufficiently considered in any 
of its relations in a work intended for the general practi- 
tioner. There is not so much to cure in an idiot, as there 
is to develop. As an illustration of the facial expression 
and general appearance of an extremely idiotic person, I give 
the preceding likeness of a young man (Fig. 19) in the JSTew 
York City institution on Randall's Island. When I first 
saw this individual several years ago — when the photograph 
was taken — he was filthy in his habits, and had not as high 
a degree of intelligence as a well-trained dog. Through 
persevering efforts on the part of his instructors, he has be- 
come neat in his person, has learned to say a few words, and 
is altogether more advanced intellectually than he was at 
the time mentioned. His cranial development is, however, 
so small that any very material progress is not to be ex- 
pected. 1 

Dementia. — Dementia may be primary, but such is very 
rarely the case, it being in the vast majority of instances the 
consequence of an acute attack of insanity, or incident to 
old age. 

The characteristic feature of dementia is mental weak- 
ness, and this is shown as regards the emotions, the intel- 
lect, and the will. The former are not held under control, 
slight matters bring them into inordinate action, and tears 
are shed, and laughter excited, when there is neither ade- 
quate cause for one or the other. The intellect is affected 
in all its parts. The power of application, or of fixing the 
attention, is materially lessened, and this is doubtless one 
reason why imperfect ideas are formed of very simple mat- 

1 For full information on the subject of idiocy, the reader is referred to 
Idiocy and its Treatment by the Physiological Method, by Edward Seguin, M. 
D., New York, 1866, and a Manual for the Classification, Training, and Educa- 
tion of the Feeble-Minded, Imbecile, and Idiotic, by P. Martin Duncan, M. D., 
and William Willard, London, 1866. 



INSANITY. 



3T5 



ters, and why it is so difficult to conceive a series of con- 
nected thoughts. The memory, especially for recent events, 
is weakened to an extreme degree, and the delusions of the 
patient, if still present, are constantly undergoing change 
from the impossibility of recollecting them. Volition is al- 
most entirely abolished. The patient is altogether con- 
trolled by others, the idea of offering opposition to their 
wishes never entering his mind. 



Fig. 20. 




The facial expression of a patient affected with dementia 
is not always characteristic, and this mainly for the reason 
that the physical health is generally good. The deficiency 
of mental power is, however, readily perceived in the ma- 



376 DISEASES OF THE BRAIN. 

jority of cases, when the attempt is made to excite the 
brain to action. The failure of the face to respond to the 
ideas sought to be conveyed becomes very evident. 

An excellent representation of a patient affected with 
dementia is given in the preceding woodcut (Fig. 20). 

Having thus very cursorily considered the symptoms 
and course of insanity in its several forms, I come in the 
next place to the discussion of certain points common to all 
the varieties. In so doing I shall still refer only to general 
principles. 

Causes. — Among the causes inherent in the individual, 
none is so powerful in its action as hereditary tendency. 
This may show itself not only by the fact that ancestors 
have been insane, but that insanity in the descendants may 
have resulted from hysteria, epilepsy, catalepsy, or some 
other general nervous affection in them. It often happens, 
too, that the disease, like many others known to be hered- 
itary, skips a generation. 

Insanity is more common in males than in females, 
though the difference is not so great as many suppose. 

The period of life between twenty -five and forty-five is 
that at which insanity is most liable to make its appearance. 
Cases are on record of infants having manifested unequivo- 
cal symptoms of mental aberration, but the affection is not 
often met with under the age of puberty. 

The civil condition of the individual, as regards marriage 
or celibacy, exercises an effect over the causation of insanity. 
Statistics show that celibates of both sexes are more liable 
than the married. So far as males are concerned, this result 
is probably due to the fact that in celibacy, as a rule, the 
mode of life is more irregular. Insanity is assuredly more 
common among civilized than uncivilized nations, but, as 
regards the different classes of individuals who go to make 
up a civilized community, it is very certain that the refined, 
educated, and wealthy classes, are not so liable to insanity as 
the lower orders. The exciting causes are both moral and 



INSANITY. 377 

physical. Of the former, emotional disturbance, grief, ter- 
ror, disappointed affection, anxiety, great joy, etc., stand 
first in influence. It is doubtful if moderate intellectual 
exertion ever, of itself, causes insanity. It is only when the 
brain is worked night and day, to the deprivation of sleep, 
and without sufficient change, that insanity results from 
mental labor. Continual thinking on one subject is the 
most effectual way of producing insanity by the action of 
the brain. 

Among the physical causes, drunkenness, the use of 
opium and other narcotics, excessive venereal indulgence, 
masturbation, blows on the head, exposure to severe heat or 
cold, the puerperal state, and certain diseases, may be re- 
ferred to. 

Diagnosis. — The principal point to be considered under 
this head is the discrimination of the real from the feigned 
disease. The necessity for making the distinction, generally 
arises from the simulation of insanity by criminals. Such 
pretenders are, in general, discovered without difficulty, 
from the facts that they overact their parts, are not pos- 
sessed of sufficient knowledge to carry out the fraud con- 
sistently, and are deficient in the perseverance and force of 
character requisite to success. 

The antecedents of the individual must be carefully in- 
quired into, as well as his actual condition. Watching him 
when he thinks he is not observed, and the administration 
of ether by inhalation, will generally suffice to expose the 
pretender. 1 

Prognosis. — This depends very greatly upon the form of 
insanity present, and upon the possibility of procuring suit- 
able treatment. Acute mania, with depression, general pa- 
ralysis, and dementia, are the most unfavorable types with 
which we have to deal. Either of the uncomplicated forms, 

1 For an exellent monograph on this subject, the reader is referred to 
Etude Medico-Legale sur le simulation de la Folie, par le Docteur Armand Lau- 
rent, Paris, 1866. 



378 DISEASES OF THE BRAIN. 

or acute mania with, exaltation, is much more readily cured. 
The older the patient when the disease appears, the more 
unfavorable the prognosis for all ages over puberty, except 
for very early life. The existence of hereditary tendency, 
and the habit of using alcohol and other narcotic substances 
to excess, likewise lessen the prospect of recovery. 

Morbid Anatomy and Pathology. — The fact that after death, 
in cases of insanity, no appearances are to be found within 
the cranium to which the disease existing during life could 
fairly be attributed, is no proof of the absence of changes 
from the normal condition. The difficulty may be with the 
blood circulating through the brain, and in the inadequacy 
of our means of examination, and it is well known that we 
are as yet scarcely on the threshold of inquiry into altera- 
tions of cellular structure, only discoverable by careful prep- 
aration of the nervous tissue, and through microscopical 
examination. Still, even with all these unfavorable circum- 
stances, in the great majority of fatal cases of insanity pal- 
pable deviations from the normal structure are observed. 
One fact may be considered as established, and that is, that 
the morbid alterations are by preference found in the mem- 
branes and cortical substance of the brain, and that those 
changes are the result of congestion and inflammation. 
Thus there are thickening and opacity of the membranes, 
adhesions, effusion of serum, and softening of the cortical 
substance. Histologically the changes are those of defective 
nutrition and degeneration — leading to the formation of 
connective tissue in superabundance at the expense of the 
nervous substance, and the degradation of this latter into 
fat, amyloid bodies, pigment, etc. 

The pathology of insanity is readily deducible from the 
morbid anatomy, and from an attentive consideration of 
the symptoms observed during life. Many cases, especially 
those of temporary insanity, are clearly the result of con- 
gestion, and others, such as those of acute mania, owe their 
first and most prominent symptoms to a like cause. In 



INSANITY. 379 

other cases, exhaustion of the brain-tissue is the immediate 
cause. From excessive use, and insufficient repair, there is 
actually what may be called a chemical atrophy of the cere- 
bral substance, and healthy brain-action is, moreover, in such 
cases generally rendered, much more difficult from the fact 
that the products of nerve disintegration are not removed. 

Insanity is often the result of alterations in the normal 
qualities of the blood. The influence of many substances 
in producing mental aberration is well known, and there is 
no doubt that their power is, to a great extent, due to their 
entrance into the blood, and their consequent circulation 
through the cerebral vessels. Among these, alcohol, opium, 
Indian hemp, belladonna, and bromide of potassium, may 
be mentioned. I have, in a memoir 1 upon the subject, cited 
several cases of positive mania caused by the excessive use 
of bromide of potassium. The accumulation of either urea 
or bile in the blood is well known to produce mental de- 
rangement, and there is no doubt that other morbid agents, 
such, for instance, as malaria and the poison of typhus, will 
give rise to a like result. Irritations in different parts of 
the body may, by reflex action, give rise to insanity. The 
influence is probably exerted through the sympathetic nerve 
on the vaso-motor nerves. I have seen two cases of acute 
mania caused by worms in the alimentary canal, and one by 
indigestible substances. Temporary insanity is frequently 
the result of such causes. 

The insanity of women generally has a reflex origin. 
The so-called puerperal mania is a variety which differs in 
no essential respect from ordinary cases of acute mania. 
Irritations of the genital organs, especially of the ovaries, 
may give rise to all the forms of insanity mentioned, with 
the exception, perhaps, of general paralysis. A few weeks 
ago I was consulted in the case of a lady who had become 

1 On some of the Effects of the Bromide of Potassium, when administered 
in Large Doses. Journal of Psychological Medicine, January, 1869, vol. iii., 
p. 46. 



380 DISEASES OF THE BRAIN. 

insane clearly from the irritation caused by chronic metritis. 
A more marked case of acute mania, with depression, and a 
more determined disposition to suicide, I have rarely wit- 
nessed. 1 In these cases of blood-poisoning and reflex irrita- 
tion it is not to be expected that morbid changes will gen- 
erally be discovered in either the brain or its membranes. 
Occasionally, however, such alterations are eventually pro- 
duced. 

Treatment. — The fact is daily becoming more evident 
and more generally admitted that insanity is to be treated 
as a materia] disease, and not as a metaphysical nonentity. 
It is therefore incumbent on the general practitioner to 
make himself acquainted with the principles involved in the 
pathology and treatment of the very important class of dis- 
eases now under consideration. Besides, although he may 
not have the facilities for continuing the treatment of insane 
patients, he is called to them, in the first instance, at a time 
when they are most susceptible of cure, and it is on his 
opinion that measures as to personal restraint, or custody 
of property, are taken. The first thing to do in the case of 
an insane person is to provide competent attendance ; for, 
as I have already said, there is no knowing to what extremes 
his delusions or impulses may carry him. Even in the sim- 
ple, uncomplicated cases of illusions and hallucinations, this 
must be secured, for in an instant the false perceptions may 
be accepted as realities, and acts performed in accordance 
with them. 

Then inquiry should be made as to the cause, and efforts 
directed to its removal. If this can be ascertained to be 
eccentric, a good prospect of success may be entertained. 

Examination should always be made with reference to 
the state of the cerebral circulation, and here the ophthal- 

1 For a very full account of this important division of the subject, the reader 
is referred to Die Beziehungen der krankhaften Zustande und Vorgange in 
den Sexual-Organen des Weibes zu Geistesstorungen, by Dr. C. E. Louis Mayer, 
Berlin, 1870. 



INSANITY. 3 SI 

moscope is capable of giving very definite indications. It 
will very often be found that there is hyperaemia of the 
brain, and then the treatment recommended under the heads 
of cerebral congestion and cerebral haemorrhage must be 
carried out. Latterly I haye used the bromide of lithium 
in cases of acute mania, and haye more reason to be satis- 
fied with it than with any other medicine calculated to di- 
minish the amount of blood in the cerebral yessels, and to 
calm any nervous excitement that may be present. The 
rapidity with which its effects are produced renders it spe- 
cially applicable in such cases. The doses should be large 
— as high as sixty grains or even more — and should be re- 
peated every two or three hours till sleep be produced, or 
at least till half a dozen doses be taken. After the patient 
has once come under its influence, the remedy should be 
continued in smaller doses, taken three or four times in the 
day. 

In cases of cerebral congestion attended with illusions 
and hallucinations, but without mania, the other bromides 
will answer the purpose — preferably the bromide of sodium. 
They may also be given in the more violent forms if the 
bromide of lithium cannot be obtained. 

TVTien the mental excitement is in a measure subdued, 
and the patient sleeps reasonably well, the dilute phosphoric 
acid of the pharmacopoeia is an admirable remedy for re- 
storing strength to the exhausted system. It may be given 
in doses of half a drachm, properly diluted with water, after 
each meal. 

Schroeder van der Kolk 1 has pointed out the efficacy 
of aloetic purges in certain cases of emotional insanity of a 
depressing character due to accumulations in the colon. I 
have frequently had occasion to be gratified at the success 
obtained. The aloes should be administered in doses of 

1 Die Pathologie und Therapie der Geisteskranken auf anatomisch physio- 
logischer Grundlage, Braunschweig, 1863, p. 185, et seq. 

Also translation by Dr. James T. Rudall, London, 18 TO, p. 134. 



382 DISEASES OF THE BRAIN. 

about five grains three times a day. I am in the habit of 
combining it with three grains of inspissated ox-gall, and 
with excellent results. Under this very simple system of 
medication I have frequently seen the most intense melan- 
choly disappear in a few days. 

In calming maniacal excitement I have occasionally used 
opium. When it is necessary to obtain an immediate effect, 
nothing can equal morphia hypodermically administered. 
But its continuance, I am sure, is almost always productive 
of bad results by increasing cerebral congestion. Indian 
hemp, digitalis, and hyoscyamus, are occasionally useful. The 
application of cold water, in the form of the douche, is a ra- 
tional method of relieving intra-cranial hyperemia and mod- 
erating nervous excitement. It should be used with caution. 
The warm bath will also prove beneficial in some cases. 

In general paralysis, whatever means of treatment are 
employed should be used in the earliest stages to obtain the 
greatest measure of success. I have several times derived 
benefit from the use of the iodide of potassium in large 
doses — not that it has cured, but that it has mitigated the 
violence of the symptoms, and put some check to the ad- 
vance of the disease. Liedesdorf ' declares that, though he 
has only used it himself in syphilitic cases, there is evidence 
in favor of its utility as opposing some obstacle to the on- 
ward course of the affection. He also recommends the cold 
douche in all stages. In my own practice I have employed 
phosphorus and strychnia with beneficial results. 

In dementia, tonics and stimulants are generally useful. 
Of the former, iron and quinine may be employed with ad- 
vantage, and especially phosphorus, phosphoric acid, and 
strychnia, the latter being combined with either of the 
others. 

A great many more remedies might be mentioned, and 
in a work specially devoted to insanity I should call atten- 
tion to them, but I have said enough to indicate the course 

1 Lehrbuch der psychischen Krankheiten, Erlangen, 1865, p. 229. 



INSANITY. 383 

of the treatment so far as medication goes. 1 There are a 
few remarks yet to make under this head in regard to means 
which, in my opinion, should not be used. 

Counter-irritants are rarely if ever useful. I have never 
seen any benefit derived from them. 

General bloodletting is never necessary. It will calm 
a highly-maniacal patient, but so will a sufficiently severe 
blow on the head. 

The hydrate of chloral is a dangerous remedy. I have 
seen it produce great increase in the maniacal excitement. 
Its first effect is always to augment cerebral congestion, and, 
though it eventually lessens the amount of blood in the brain 
and calms nervous irritability, the dose must be large for 
these results to be obtained, and the same ends can be ac- 
complished by safer means. 2 

The moral treatment can only be effectually carried out 
by secluding the patient from society at large, and especially 
from his immediate family. It is not always necessary to 
confine him in an asylum, but it is necessary in the great 
majority of cases to place him in such a situation as will 
secure for him safety, the companionship of sensible people, 
and the influence and control of some one skilled in the 
philosophy of the human mind, in the anatomy and physi- 
ology of the brain and nervous system, and in medical sci- 
ence generally. The great difficulty with asylums is, that 
they contain only insane people, and the prevalent idea 
among the public — and it is often carried out by the officers 
of asylums — is, that institutions for the insane are simply 
places in which dangerous or troublesome maniacs are to be 
kept in safety. My own idea is, that the best of all places 

1 Of all writers on psychological medicine, no one seems to have more un- 
bounded faith in drugging than Kieser — Elemente der Psychiatrik, Breslau und 
Bonn, 1855. 

3 For my views on this subject, based on experiments, the reader is referred 
to my memoir entitled : On the Physiological Effects and Therapeutical Uses of 
the Hydrate of Chloral, New York Medical Journal, February, 1870, p. 469. 



384 DISEASES OF THE BRAIN. 

for a lunatic of any kind is the family of a physician, of 
such a one as I have just mentioned. The association of 
an insane person day after day, year after year, with others 
similarly affected, with scarcely the least contact with peo- 
ple of sound minds, is certainly in opposition to the first 
principles of true psychological medicine. 

Asylums are, however, for the present at least, necessary, 
and it is with great pleasure that I am enabled to state, after 
having visited a great many institutions for the insane in 
Great Britain and on the Continent, that American asylums 
are very far superior in every respect. 

It has been said that it is useless to attempt to reason a 
lunatic out of his delusion. Perhaps there is truth in this 
when serious structural lesions exist in the brain. The false 
intellectual conception is then a fixed result of the altered 
brain- tissue, and is just as direct a consequence of cerebral 
action as is a thought from a healthy brain. Still, we know 
that in health it is sometimes possible by argument to coun- 
teract the most firmly-rooted ideas, and there is no reason 
why the same result may not occasionally be produced by 
arguments addressed to a person with an insane mind. We 
know, in fact, that this end is at times accomplished, and 
that, by never for an instant admitting the truth of an in- 
sane delusion, and at suitable times — not obtrusively, but 
when occasion offers — urging such arguments against it as 
would be convincing to persons of sound minds, the lunatic 
comes at last to see the falsity of his ideas, and to laugh at 
them himself. Little by little he loses faith in his perverted 
reason, and, though he may take up another delusion, the 
last is held with much less tenacity than the first. 

Amusements are generally of service, and a proper sys- 
tem of rewards and punishments is understood by all but the 
most furious maniacs. Kindness and forbearance, supported 
by firmness, will not altogether fail in their influence with 
even the most confirmed and degraded lunatics. 



SECTION II. 
DISEASES OF THE SPINAL COED. 



CHAPTEE I. 

SPINAL CONGESTION. 

Though congestion of the spinal cord, like that of the 
brain, is of two kinds, active and passive, jet the symptoms 
and general course of the two varieties are so generally alike, 
that nothing would be gained by considering them sepa- 
rately. 

Symptoms. — The symptoms of spinal congestion are re- 
ferable to the cord and to those parts of the body below the 
seat of the lesion. The most prominent local phenomenon is 
pain, which is rarely acute, but is described as a dull, aching 
sensation similar to that experienced in the back after severe 
and long-continued muscular exertion in a stooping attitude. 
This pain is increased by the recumbent posture and by 
standing, if the lower part of the cord be its seat ; but press- 
ure, if steadily applied, does not augment it. A sudden 
blow or a shock, such as that produced by making a false 
step, aggravates it to a considerable extent. 

A sensation of heat is occasionally experienced in the 
cord, which is not unpleasant, and which is not affected by 
pressure. 

25 



386 DISEASES OF THE SPINAL CORD. 

With the local symptoms there are others still more no- 
table perceived in the parts of the body below the seat of the 
disease. Thus, if, as is very generally the case, the lesion be 
situated in the dorsal or lumbar region, there are disturb- 
ances of sensibility and motility in the lower extremities. 
The various sensations indicating anaesthesia are present, and 
are usually first experienced in the skin covering the under 
surface of the toes. Formication, " pins and needles," tin- 
gling, and a feeling as if the toes are swollen, are noticed. It 
is rarely the case that the anaesthesia is complete. Its ex- 
tent and exact situation may be accurately determined by 
the aesthesiometer. 

Sometimes there is hyperesthesia, and occasionally both 
conditions coexist. The extent of either may be accurately 
measured with the eesthesiometer. Shooting pains in the 
limbs and along the course of the nerves coming from the 
diseased part of the cord are now and then present, but 
they are not a prominent feature in simple congestion. 

A sensation of constriction is at times complained of, and 
is referred to the body or one or both of the limbs. It is 
compared to the feeling which would be produced by a tight 
cord or encasement in an unyielding garment. It is rare in 
uncomplicated spinal congestion. According to the situa- 
tion of the lesion, there are pains either in the abdomen, 
chest, or both, and there may be dyspnoea and palpitation 
of the heart. In three cases under my care, the difficulty 
of breathing and irregular cardiac action were prominent 
features. Similar cases are cited by Ollivier x (d' Angers). 
The temperature of the parts of the body below the lesion is 
always reduced, from the fact that the vaso-motor nerves 
are involved. 

Erections of the penis are common, especially after the 
patient has been in the recumbent position for some time. 

The most striking phenomena of spinal congestion are 

1 TraitS des Maladies de la Moelle Epiniere. Troisieme edition. Paris, 1837, 
tome iii., pp. 1-137. 



SPIXAL CONGESTION. 38 Y 

those connected with the alterations of motility. Para- 
plegia is always present to some extent, though it is rarely 
complete. Thus the patient, though unable to walk, can 
generally move the legs when sitting down or lying in bed. 
Twitchings of the muscles are occasionally present, but not 
often to a severe degree. 

The loss in the power of motion, like the alterations in 
sensibility, is only present in those parts of the body situ- 
ated below the diseased parts of the cord. The bladder is 
very generally affected, either in its own muscular tissue or 
in its sphincter. In the first case, there is a difficulty of ex- 
pelling the urine, owing to loss of expulsive power, and this 
is aggravated by paralysis of the abdominal muscles, or there 
is incontinence of urine from paralysis of the sphincter. 
Both conditions may coexist, and then, when a sufficient 
quantity of urine has accumulated in the bladder, it dribbles 
away. In such a condition, the -bladder is never entirely 
empty, and the urine is passed alkaline and fetid. 

The sphincter of the rectum is sometimes involved, pro- 
ducing involuntary evacuation of the faeces, but obstinate 
constipation from paralysis of the abdominal muscles, and 
consequent loss of expulsive power, are much more common. 
Reflex excitability is, according to my experience, invari- 
ably lessened, and is sometimes entirely abolished. 

The electro-muscular contractility of the paralyzed mus- 
cles is always more or less diminished, though not to the 
same extent as in some other affections of the cord. As a 
general" rule, the farther the muscle is from the centre the 
less is its electro-muscular contractility. 

The tendency of spinal congestion is to extend itself and 
eventually to involve the whole cord. In the active form 
of the disease, this process often takes place with great 
rapidity, and the symptoms generally are more pronounced 
and succeed each other with more promptness. The phe- 
nomena of spinal congestion are always rendered more de- 
cided by the patient's assuming the recumbent posture. He 



388 DISEASES OF THE SPINAL COED. 

is hence more paralyzed in the morning before rising from 
bed than in the evening before he retires. This is due to 
the fact that the position in question, especially if he lies 
on his back, allows the spinal blood-vessels to become more 
readily distended. It is the same thing, as regards the cord, 
that keeping the head in a dependent position would be as 
regards the brain. 

Bed-sores are not common. Radcliffe • seems to assert 
that they are never met with. Brown-Sequard a says an ul- 
ceration upon the sacrum or nates is not rare in this affec- 
tion. Ollivier 8 does not mention them in his account of the 
disease. Of sixty-two cases of spinal congestion which have 
been under my care during the last six years, or in which I 
have been consulted, bed-sores occurred in but two, and in 
these there was reason to believe they were not the special 
result of the lesion of the cord. 

According as the antero-lateral or posterior columns are 
mainly affected, the symptoms of spinal congestion differ. 
Thus, in the former case, the phenomena are chiefly mani- 
fested as regards motility, in the latter as regards sensibility. 
Generally both sets of columns are involved. In spinal 
anaemia, as we shall presently see, this is not the case. 

Causes. — The most common cause of spinal congestion, 
according to my experience, is exposure to intense cold. 
This was the alleged cause in eighteen of the sixty-two cases 
previously referred to as having come under my observation. 
Fevers appear to be next in frequency, especially those of 
malarious origin, nine cases being referred to this influence. 

Yenereal excesses were the apparent cause in five cases, 
and maintaining the erect posture for a long time was the 
obvious cause in three cases. This last influence was very 
well marked in the case of an eminent lawyer of this city, 
who became suddenly affected with spinal congestion after 

1 Reynolds's System of Medicine, vol. ii., p. 622. 

2 Lectures on the Diagnosis and Treatment of the Principal Forms of Paral- 
ysis of the Lower Extremities, Philadelphia, 1861, p. 69. 3 Op. cit. 



SPINAL CONGESTION. 389 

making a speech of several hours' duration. The suppres- 
sion of a customary discharge, such as the menstrual.now or 
a haemorrhoidal bleeding, is likewise liable to induce con- 
gestion of the cord. Three cases under my charge were 
thus caused. Two were the result of blows, one of severe 
muscular exertion, and in the remainder no cause could be 
with any degree of certainty ascertained. 

Among the effects of working under compressed air, 
spinal congestion must be included. Drs. Babington and 
Cuthbert, 1 of Dublin, have called attention to this fact, and 
Dr. Clark, 3 of St. Louis, has recently brought forward sev- 
eral additional cases occurring in the workmen in the cais- 
son used in building the bridge over the Mississippi River. 

Passive spinal congestion may be caused by any obstruc- 
tion to the return of blood by the veins, such as cirrhosis of 
the liver, pregnancy, abdominal tumors of various kinds, dis- 
eases of the lungs or right side of the heart, and the long- 
continued maintenance of the dorsal decubitus. 

Diagnosis. — Spinal congestion is liable to be confounded 
with several other affections, and with some to the great in- 
jury of the patient. Thus it may not be distinguished from 
spinal anaemia, a condition likewise giving rise to para- 
plegia, but of which the treatment is very different. 

It may be diagnosticated from this affection by the facts 
that in spinal anaemia there is pain in the cord, increased by 
pressure on the spinous processes of the vertebrae, or, if there 
is no spontaneous pain, such pressure causes it ; by the dis- 
turbance induced in the cranial, thoracic, or abdominal 
viscera, according to the part of the cord affected, being 
much more prominent ; by the circumstance that women are 
more generally its subjects ; that there is often a previous 
affection generally of the urinary organs which has caused 
the anaemia ; but, above all, by the fact that in spinal anaemia 

1 Paralysis caused by working under Compressed Air, Dublin Quarterly Jour- 
nal of Medical Science. 

2 St. Louis Medical and Surgical Journal. 



390 DISEASES OF THE SPINAL CORD. 

the symptoms are less strongly marked after the patient has 
been lying down some time, whereas the reverse is the case 
in congestion. 

Spinal anaemia never produces any urinary difficulty, 
although such trouble may cause spinal anaemia. In a case, 
therefore, in which there was doubt as to the spinal cord 
being in a state of congestion or anaemia, the order of se- 
quence, as regards the paraplegia and bladder-difficulty, 
would seem to render the diagnosis exact. In spinal anae- 
mia the bladder is affected before the paraplegia appears ; 
in spinal congestion the paraplegia comes on before the blad- 
der is involved. 

In spinal anaemia there is no formication, pricking, 
tingling, or other sensation indicative of anaesthesia. Hy- 
peraesthesia is, on the contrary, exceedingly common. 

The further diagnostic marks will be considered when 
we come to the subject of spinal anaemia. 

Congestion is distinguished from inflammation of the 
cord by the facts that in it the jerkings of the limbs are slight, 
that the paralysis is not so extreme, that the urine is never 
alkaline, that the pain in the cord is less, and by the infre- 
quency of the feeling of constriction at the upper limit of 
the lesion. 

From meningitis it is diagnosticated by the absence of 
spasms in the muscles of the back, and by the fact that 
movements of the paralyzed limbs do not cause pain. 

Prognosis. — In simple uncomplicated spinal congestion 
the prognosis is not unfavorable, if, in addition, the case be 
put under suitable treatment at an early period. It must 
be remembered, however, that there is a tendency to inter- 
stitial changes, and that, if the vessels of the cord be left for 
a long time in a state of turgidity, it may be impossible to 
prevent structural alterations of greater severity. Yery few 
of the cases that have come under my own immediate notice 
were in the first stage of the affection, but yet twenty-three 
were entirely cured, nineteen were greatly relieved, seven 



SPINAL CONGESTION. 391 

are still under treatment, six are known to have died, and 
the rest were lost sight of, most of them not having been 
under my immediate charge. , 

Morbid Anatomy. — The post-mortem appearances in cases 
of congestion of the spinal cord are either in the cord prop- 
er or its membranes. As regards the first, section shows 
increased vascularity both of the gray and the white sub- 
stance, especially if microscopical examination be made. 
The capillaries will be found increased in size and more 
numerous than in the normal condition. 

The membranes of the cord contain very large and very 
tortuous vessels, and in congestion they are rendered still 
larger and more complex in their anastomoses. The press- 
ure which they are capable of exerting upon the cord is not 
inconsiderable. 

It is almost invariably found that the cerebro-spinal 
fluid is increased in quantity. 

These evidences of congestion are sometimes extremely 
limited in their extent, at others the whole length of the 
cord is involved. 

Pathology. — The symptoms which result from congestion 
of the cord are of two distinct classes: increased ex- 
citability from hypergemia, and interruption of the proper 
functions of the cord from pressure. The former, in the 
main, results from the increased amount of blood in the 
gray matter and white substance ; the latter from the en- 
larged meningeal vessels and the increased amount of cere- 
bro-spinal fluid, which, in the form of serous effusion, is the 
result of their turgidity. As one or the other of these con- 
ditions predominates, we have some symptoms more promi- 
nent than others. Thus hypersesthesia indicates rather hy- 
peremia of the gray substance, anaesthesia pressure upon the 
white substance. Twitchings, when present, are likewise 
the result of over-excitation of the gray tissue ; while motor 
paralysis is induced by pressure upon the antero-lateral col- 
umns. 



392 DISEASES OF THE SPINAL CORD. 

The modifications which may be produced in the inten- 
sity of the symptoms by the position of the body show the 
effect of pressure very clearly. In the recumbent posture 
on the back, the blood gravitates in large amount to the 
spinal vessels, pressure on the cord is increased, and the 
phenomena of anaesthesia and paralysis are more strongly 
marked. Again, causes which increase the activity of the 
circulation, such as alcoholic stimulants, and others which 
directly augment the amount of blood in the cord, such as 
strychnia and phosphorus, invariably increase the hyperes- 
thesia and induce muscular twitchings, even if they have 
not previously been observed. 

Treatment. — In cases of spinal congestion which come on 
suddenly, and which are therefore acute in their character, 
such as result from the sudden arrest of an habitual dis- 
charge, blood may be drawn locally from the spinal region 
by cups or leeches. The best place for the application of 
the latter is the verge of the anus, and I have several times 
witnessed very decidedly satisfactory results from their use 
in this situation. 

Purgatives are likewise beneficial, and preference should 
be given to those which produce watery evacuations, as 
thereby the overloaded vessels are relieved, and the absorp- 
tion of the superabundant cerebro-spinal fluid facilitated. 
Nothing can be better for this purpose than the sulphate of 
magnesia given in doses of a drachm two or three times 
a day. 

In this form the ergot of rye may be given with advan- 
tage from the very inception of the disorder. In the more 
chronic form it is indispensable. It should be administered 
in very much larger doses than are laid down in the text- 
books on materia medica. I am in the habit of using it, in 
this and analogous spinal diseases, in doses of a drachm of 
the fluid extract three times a day. The action of the ergot 
is to lessen the diameter of the blood-vessels of the cord by 
its constringing power over the organic muscular fibre en- 



SPINAL CONGESTION. 393 

tering into the composition of their walls. Ten years ago x 
I spoke as follows : " But I have recently ascertained by 
actual experiment that ergot does exert the influence in 
question. I prepared a weak aqueous infusion of this sub- 
stance and placed it on the web of a frog's foot under the 
microscope. In a few moments contraction of the capilla- 
ries ensued, and they became so small as not to allow of the 
passage of the blood-corpuscles. This experiment I have 
repeated several times, and am perfectly satisfied that the 
result is as I have stated. More, I have frequently injected 
small quantities of the infusion into the stomach of frogs, 
and contraction of the capillaries of the web always fol- 
lowed." 

This was certainly the first demonstration of this very 
important action of ergot. 

Since that time I have given it in a large number of 
cases of diseases of the spinal cord, congestion among them, 
in which it was necessary to diminish the amount of blood 
in the spinal vessels, and I am entirely satisfied that such is 
its effect ; but I never obtained its full influence till, in ac- 
cordance with the suggestion of my friend Dr. A. Jacobi, 
of this city, I adopted the practice of giving it in what may 
be called very large doses. Among the cases which first 
came under my care, since my residence in 'New York, was 
that of Mr. W., of Tennessee, who had become affected with 
congestion of the cord, from exposure to cold and dampness. 
When I first saw him he was unable to walk without the 
assistance of crutches, and a man on each side of him hold- 
ing his shoulder. He had paralysis of the bladder, which 
had come on after the paraplegia, and a constant, dull, 
aching pain in the loins. There were also occasional start- 
ings of the legs, especially after he had gone to bed. All 
his symptoms were worse in the morning. I at first gave 
him ten drops of the fluid extract of ergot three times a day, 

1 A Clinical Lecture on Chronic Myelitis, delivered in the Baltimore Infir- 
mary, March 16, 1861. American Medical Times, June 15, 1861, p. 379. 



394 DISEASES OF THE SPINAL CORD. 

but, continuing this for two weeks without effect, I at once 
increased the doses to a teaspoonful. In less than a week 
the effects were manifest. Sensibility began to return in 
the extremities, the strength increased, the bladder began 
to contract on its contents, the lumbar pains ceased, and by 
the end of a month he had entirely recovered. A few weeks 
afterward he had a relapse, but the ergot, taken as before 
for ten days, again restored him, and he has since remained 
perfectly well. 

I cite this case because it is one in which nothing else 
but the ergot was given, and as one in which its influence 
was twice distinctly manifested. 

Belladonna is also a valuable remedy in spinal conges- 
tion, especially when there is paralysis of the sphincter, or 
when the pain in the back is severe. The tincture, in 
doses of fifteen drops three times a day, may be employed, 
and a belladonna plaster may be applied to the painful re- 
gion of the spine. 

The hot douche — the water being of the temperature of 
98° Fahr. — to the spinal column is an excellent means of 
determining the blood from the deep to the superficial ves- 
sels. The water should be allowed to fall from the height 
of about two feet upon the naked back over the diseased 
part of the cord every day for about ^.Ye minutes. Dry 
cups are also valuable adjuncts. 

Electricity is always useful. The constant current should 
be applied to the spine over the affected part of the cord, 
the positive pole being held at the upper limit of the lesion, 
and the negative rubbed up and down all the part below. 
The duration of the application should not exceed ten min- 
utes. By this means the calibre of the spinal vessels is 
probably lessened. At any rate the downward current cer- 
tainly is beneficial, while the upward increases the intensity 
of the symptoms. 

The induced current should be used to the paralyzed 
muscles, so as to excite them to contract. In this way their 



SPINAL CONGESTION. 395 

nutrition is promoted, and any tendency to atrophy from 
disuse obviated. 

The primary current should not be employed more fre- 
quently than every alternate day. The induced may be 
used every day for half an hour or longer, short of causing 
fatigue. 

I will only add that strychnia and phosphorus should 
never be administered in congestion of the cord, as their ac- 
tion is the very reverse of that desired, and irreparable dam- 
age may be done by their use. 



CHAPTER II. 

SPINAL ANEMIA.— ANEMIA OF TEE POSTERIOR COLUMNS.— 
ANAEMIA OF TEE ANTERO-LATERAL COLUMNS. 

A deficient quantity of blood in the spinal cord, or a 
depravation in the quality of the blood circulating through 
its tissue, gives rise to two cognate, but, so far as their phe- 
nomena go, different affections. In one of these, which has 
hitherto been known as spinal irritation, the morbid action 
is in a great measure confined to the posterior columns of 
the cord ; in the other, which embraces several differently- 
named disorders, characterized by paralysis, such as reflex 
paralysis, inhibitory paralysis, spinal paresis, paralysis from 
peripheral irritation, etc., the antero-lateral columns are 
mainly affected. 

In thus specifically locating the lesions in these affec- 
tions, I am aware of the fact that post-mortem examinations 
are wanting to support thern. Nevertheless, the symptoms 
characteristic of each are so distinctly marked, and are in 
such intimate physiological relation with the regions of the 
cord specified, that I do not think I am at all exceeding the 
limits of probability. 

Betaining the name of spinal irritation, as one well 
known to the profession, it will nevertheless be understood 
that, in my opinion, the proper designation of the disease 
would be anaemia of the posterior columns of the spinal cord. 
I have arrived at this view after a very careful consideration 
and analysis of the symptoms observed in a large number 
of cases. 



SPINAL ANEMIA, ETC. 397 

The same remarks are applicable, mutatis mutandis, to 
reflex paraplegia, a symptom which I am very sure results 
from anaemia of the antero-lateral columns of the cord. 

ASMMIA OF THE POSTERIOR COLUMNS OF THE SPINAL COED. 

SPINAL ERErTATIOX. 

History. — It has been questioned by several distinguished 
authors whether such an affection as spinal irritation really 
exists as a distinct disease. Thus Yalleix ' ascribes the most 
important of its manifestations to hysteria, and regards the 
spinal tenderness present as being due to simple intercostal 
neuralgia ; Inman 2 considers the pain produced by pressure 
over the spinous processes of the vertebrae as existing in the 
muscular attachments, and as indicative of what he calls 
myalgia. Mr. Skey 3 evidently looks upon all cases of spinal 
irritation as hysterical in their character, and Niemeyer 4 
speaks incredulously on the subject, without giving any very 
decided opinion. It would be easy to bring forward other 
authorities who have expressed similar views, and I may 
have to allude to some of them more fully hereafter. In 
the recently-published nomenclature of the Royal College 
of Physicians, 6 the affection has no .place unless it be in- 
cluded under the head of hysteria. 

The first author who distinctly grouped together the 
symptoms of spinal irritation was J. Frank, 6 who, under the 
name of rachialgia, described the disorder with considerable 
accuracy, and laid the principal stress upon the local pain. 

1 Traite des nevralgies, ou affections douloureuses des nerfs. Paris, 1841, 
p. 345. 

2 On Myalgia : its Nature, Causes, and Treatment, etc. Second edition, 
London, 1860, p. 225, et seq. 

3 Hysteria, etc., New York, 1867, p. 72, et seq. 

4 A Text-Book of Practical Medicine. American edition, New York, 1869, 
voL ii., p. 258. 

5 The Nomenclature of Diseases drawn up by a Joint Committee appointed 
by the Royal College of Physicians of London. London, 1869. 

6 De Rachialgitide, in Prax. med. univ., P. II., t. i., p. 37. 



398 DISEASES OF THE SPINAL CORD. 

He was followed by Stiebel, 1 who, however, contributed lit- 
tle to our knowledge of the subject. 

Mr. J. R. Player 2 was among the first English physi- 
cians, if not the very first, to call attention to the fact that 
eccentric derangement of function may be the result of irri- 
tation of the spinal cord. Thus he says: "Most medical 
practitioners who have attended to the subject of spinal dis- 
ease must have observed that its symptoms frequently re- 
semble various and dissimilar maladies, and that commonly 
the function of every organ is impaired whose nerves origi- 
nate near the seat of disorder. The occurrence of pain in 
distant parts forcibly attracted my attention, and induced 
frequent examination of the spinal column ; and, after some 
years' attention, I considered myself enabled to state that, 
in a great number of diseases, morbid symptoms may be dis- 
covered about the origins of the nerves which proceed to the 
affected parts, or of those spinal branches which unite them ; 
and that, if the spine be examined, more or less pain will 
commonly be felt by the patient on the application of press- 
ure about or between those vertebrae from which such nerves 
emerge." 

The term " spinal irritation " appears to have been first 
used by Dr. C. Brown, 3 of Glasgow, who, in a very excellent 
paper, gives a picture of the disorder which cannot fail to be 
recognized as truthful and exact by those who have wit- 
nessed several cases of the affection. He insists upon not 
confounding the complaint with those organic diseases of 
the vertebrae and spinal cord which some of its symptoms 
cause it to resemble, points out the variation of the phe- 
nomena according to the seat of the spinal tenderness, and 
inculcates the employment of rest and counter-irritation as 
the most effectual remedies. His ideas of the pathology of 

1 Uber Neuralgiea Rachitica, Rust's Magazine, t. i., c. xvi., p. 549. 

2 Quarterly Journal of Science, vol. xii., p. 428. Quoted by Teale. 

3 On Irritation of the Spinal Nerves. Glasgow Medical Journal, No. II., 
May, 1828. 



SPINAL ANJEMIA, ETC. 399 

the disease are : " That the immediate cause of the pain of 
the back and breast is spasm of one or other of the muscles 
arranged along the spine altering the position of the ver- 
tebrae, or otherwise compressing them as they issue from the 
spinal marrow. 

" That this spasm in many instances is strictly a local 
disease, produced by fatigue, wrong posture, or other causes, 
and quite unconnected with the state of the brain, spinal 
marrow, or nervous system in general. 

" But that, in other formidable instances, this partial, 
spasmodic, or wrong action of the muscles, is owing to a 
faulty state, perhaps an enlargement, of the vessels of the 
brain or spinal marrow. This state of the brain, as in many 
other diseases, gives rise to spasm or even to convulsion of 
certain muscles ; which partial symptom, from its severity, 
attracts the chief attention. This local affection is confined 
to those portions of the spine where there is the greatest 
motion, and where, of course, the muscles having the great- 
est activity are most liable to deranged action or spasm. I 
imagine that this view of the subject is illustrated and per- 
haps confirmed by various symptoms which were observed 
in the different cases, and which without it were very in- 
comprehensible. The partial palsy, the affection of the 
sight, the giddiness of the head (for I find that this was a 
prominent symptom in several cases, especially in that of A. 
S.), all give some confirmation to the notion that the brain 
is affected in these severe cases." 

Dr. Darwall, 1 of Birmingham, describes several features 
of the affection with accuracy, such as those simulating car- 
diac and gastric diseases. He is inclined to believe that the 
morbid condition of the spinal cord depends mainly upon 
irregularity of the circulation, generally congestion. 

But no essay upon the subject of spinal irritation, which 
had yet appeared, was equal in thoroughness to that of Mr. 

1 On some Forms of Cerebral and Spinal Irritation. Midland Medical "Re- 
porter, May, 1829. 



400 DISEASES OF THE SPINAL CORD. 

Teale, 1 and it is to him that the views now generally held 
relative to the connection between various eccentric phe- 
nomena, such as pain, spasm, and visceral disturbance, and 
a peculiar condition of the spinal cord, are to be attributed. 
He, however, committed the great error of regarding the 
affection as being due to inflammation, and, in what for 
those days was logical accordance with this theory, he com- 
bated it with strong antiphlogistic measures. His book 
may be studied with advantage, as presenting an admirable 
account of the many diverse phases which spinal irritation 
may assume. 

Mr. Tate, a in his work on hysteria, attributes many of 
the protean manifestations of this disorder to spinal irrita- 
tion, limited, however, to the dorsal region. He fails to 
recognize it as an independent disease. His treatment con- 
sists in the application of tartar-emetic ointment along the 
whole length of the dorsal vertebrae, and strong purgation. 
He discountenances the use of leeches and blisters. 

Mr. W. R. Whatton 3 insists chiefly upon the liability 
to mistake spinal irritation for disease of the vertebrae. He 
gives a very excellent account of the symptoms. The treat- 
ment he recommends consists in the abstraction of blood, by 
leeches or cups, from the parts where the tenderness is felt, 
repeated every three or four days, and the application of 
small blisters on each side of the painful spots. Any debil- 
ity ensuing in consequence of this treatment is to be reme- 
died by the preparations of iron and quinine. 

In a clinical lecture delivered in Dublin, Dr. Corrigan 4 
relates the particulars of several cases of spinal irritation, 
successfully treated by local antiphlogistic measures, and 

1 A Treatise on Neuralgic Diseases dependent upon Irritation of the Spinal 
Marrow and Ganglia of the Sympathetic Nerve. London, 1829. 

2 Treatise on Hysteria. London, 1830. 

3 On Spinal and Spino-Ganglial Irritation. North of England Medical and 
Surgical Journal, No. III., 1831. 

4 Medico-Chirurgical Review, July, 1831, p. 182. 



SPINAL ANAEMIA, ETC. 401 

the internal use of iron. He does not, however, add any 
thing of importance to our previous knowledge of the sub- 
ject. 

Dr. Isaac Parish, 1 of Philadelphia, appears to have been 
the first American author who called attention to the affec- 
tion in question. He relates the details of several cases, 
recommends the use of counter-irritants, especially tartar- 
emetic ointment, and concludes : 

" First, that tenderness on pressure in some portion of 
the spinal cord is an attendant on many chronic neuralgic 
affections, and that, by relieving it in the manner proposed, 
these complaints are either entirely eradicated or tempora- 
rily suspended. 

" And, secondly, that the precise indications which this 
circumstance affords are not sufficiently understood at the 
present time to justify the establishment of any definite 
pathological principles applicable to the whole class of neu- 
roses." 

Dr. W. Griffin and his brother, Mr. D. Griffin, 2 of Lim- 
erick, were the next to write upon the subject. The joint 
work of these gentlemen is based upon one hundred and 
forty-eight cases, all of which are thoroughly analyzed, and 
from which very definite deductions of pathology and treat- 
ment are drawn. The essay is not excelled in importance 
by any previous contribution, and constitutes a really valu- 
able study. The conclusions which they draw are so in- 
structive that I do not hesitate (though by no means indors- 
ing them all) to transfer them without abbreviation : 

" 1. That tenderness at one or more points of the spine 
is an attendant on almost all hysterical complaints, on nu- 
merous cases of functional disorder when the hysteric dispo- 

1 Remarks on Spinal Irritation as connected with Nervous Diseases : with 
Cases. American Journal of the Medical Sciences, vol. x., 1832, p. 223. 

2 Observations on the Functional Affections of the Spinal Cord and Gangli- 
onic Nerves, in which their Identity with Sympathetic, Nervous, and Simulated 
Diseases is illustrated. London, 1834. 

26 



402 DISEASES OF THE SPINAL CORD. 

sition is not so obvious, and in many nervous or neuralgic 
affections. 

" 2. That many of the symptoms of these affections evi- 
dently depend upon a peculiar state of certain nerves, prob- 
ably at their origin, may be reproduced at any moment by 
pressure, and are often relieved by remedies applied there. 

" 3. That, in all cases of tenderness of the cervical and 
upper dorsal spine, there was nausea, or vomiting, or pain 
of stomach, or affections of the upper extremities ; but no 
pain of the abdomen, dysury, ischury, hysteralgia, or affec- 
tions of the lower extremities. 

" 4. That, in all cases of dorsal tenderness, pains affect- 
ing the abdomen, bladder, uterus, testes, or lower extremi- 
ties, were usual symptoms ; while nausea, vomiting, or 
affections of the upper. extremities, were never complained of. 

" 5. That nausea and vomiting appeared to have more 
relation to tenderness of the cervical spine, pain of stomach 
to tenderness of dorsal ; but that, when there was soreness 
of both, nausea or vomiting was still more frequent, and 
pain of the stomach scarcely ever absent. 

" 6. That, when several points or a great extent of the 
spinal column is painful and tender on pressure, local reme- 
dies are generally less effectual, and there is a strong dispo- 
sition to transference of the disordered action from one organ 
to another ; the pain or tenderness, in all such cases of trans- 
ference, shifting its place to a corresponding part of the 
spinal column, leaving the original point free, or with a 
very diminished degree of tenderness. 

" 7. That spinal tenderness is seldom or never met with 
in cases of pure inflammation, except when these accident- 
ally occur in persons previously suffering from irritation of 
the cord ; and that, when appearances of inflammation pre- 
sent themselves in any organ accompanied by a correspond- 
ing spinal tenderness, they cannot commonly be removed 
by the remedies applicable to inflammatory cases, and are 
often rendered worse by them. 



SPINAL ANJ3MIA, ETC. 403 

" 8. That there does not appear to be a complaint to 
which the human frame is liable, whether inflammatory or 
otherwise, which may not be occasionally irritated in dis- 
turbed states of the cord ; and hence that this disturbed 
state is one vast source of those complaints called hysterical 
or nervous. 

" 9. That those functional disorders connected with spi- 
nal tenderness are very often attended by some disturbance 
of the functions of the uterus, but that they are by no 
means always so, since they occur in those who are regular 
in this respect : in girls long before the menstrual period of 
life, in women after it has passed, and, lastly, in men of 
nervous susceptible habits, and in boys. 

" 10. That in fact they are not necessarily dependent 
upon any one organ ; since they are found indifferently co- 
existing with disturbance of the digestive organs solely, or 
the uterus solely, or of the circulatory or respiratory system. 

"11. That from the cases detailed we have reason to 
suppose spinal tenderness may arise from uterine disorder, 
from dyspepsia, from worms in the alimentary passages, 
from affections of the liver, from mental emotions, from the 
poison of typhus, from marsh miasmata, from erysipelatous, 
rheumatic, and eruptive fevers, and from the irritation aris- 
ing from local injury. 

" 12. That it is almost invariably found, in connection 
with gastric or abdominal tenderness, in fever ; and this 
tenderness is, probably, like the soreness of scalp, pains in 
the limbs, etc., dependent on the morbid state of the cord. 

" 13. That, whether in fever or in other complaints, it is 
met with in the situation of the eighth or ninth dorsal ver- 
tebra much more frequently than at any other part of the 
spine. 

" 14. That affections attended by spinal tenderness are 
seldom fatal ; that, even in those cases of intense irritation 
of the cord under which patients suffer extremity of pain 
for years, the event is generally favorable. 



404 DISEASES OF THE SPINAL CORD. 

" 15. That they frequently, as well as hysteria, occur 
with all the appearances of a primary affection of the ner- 
vous system. 

" 16. That affections are occasionally met with present- 
ing all the marks of the hysteric character, and perfectly 
resembling cases described as those of spinal irritation, but 
unattended by spinal tenderness or any other direct indica- 
tion of a morbid state of the cord." 

The treatment recommended consists in the removal of 
the cause if this still continues in action, purgatives, the 
application of blisters and leeches to the skin, the internal 
administration of hyoscyamus and belladonna, to lessen the 
nervous irritability, alum in cases of gastric derangement, 
and change of air and scene. 

In a subsequent work, the Messrs. Griffin 1 again discuss 
the subject, but bring forward no additional facts. 

Dr. John Marshall 2 is confident that many visceral affec- 
tions, such as heart-diseases, asthma, phthisis, dyspepsia, 
diabetes, chorea, and even phlegmasia dolens, are frequently 
really produced or simulated by spinal irritation. Some of 
his cases of supposed functional disorder of the spinal cord 
are, however, obviously organic, consisting of congestion, 
inflammation, or softening of the organ. 

In his classical work, Ollivier 3 devotes considerable space 
to what he calls " an Affection described under the name of 
Spinal Irritation." He considers the pathological condi- 
tion to be one of congestion of the meninges of the cord, 
and bases this opinion in great part on the success which, 
according to him, ensues on the use of leeches, blisters, and 

1 Medical and Physiological Problems : being chiefly Researches for correct 
Principles of Treatment in Disputed Points of Medical Practice. London, 
1845. 

2 Practical Observations on Diseases of the Heart, Lungs, Stomach, Liver, 
etc., occasioned by Spinal Irritation, and on the Nervous System in General as 
a Source of Organic Disease. London, 1835. 

3 Traite des Maladies de la Moelle Epiniere. Troisieme edition. Paris, 
1837, t. seconde, p. 209. 



SPIXAL AXiEMIA, ETC. 405 

counter-irritant ointments. In addition, he favors the ad- 
ministration of opium, digitalis, hyoscyamus, belladonna, 
and subcarbonate of iron. 

Turck 1 regards the phenomena of spinal irritation as 
being due, first, to disorder of other organs, whereby a mor- 
bid impression is propagated along the incident excitor 
nerves to the spinal cord, or, second, to derangement of the 
capillary circulation of the cord. That is, the disease may 
be either of eccentric or centric origin. He does not ad- 
vance our knowledge beyond the point reached by previous 
authors. 

Coming again to our own country, we find that in 1S4A 
a very valuable paper was published by Prof. Austin Flint, 2 
based upon fifty-eight cases of functional disorder connected 
with an abnormal condition of the spinal cord. In this 
memoir, without going into any discussion relative to the 
pathology of the affection, Dr. Flint considers the disorder 
as giving rise to tenderness over the vertebral column, caus- 
ing alterations of sensibility, as affecting the muscular sys- 
tem, as producing abnormal mental manifestations, as affect- 
ing the digestive organs, the genito-urinary organs, the heart 
and circulation, and as causing paroxysms of sinking. He 
then considers the physical habits of the patients, the results 
of medical treatment, the probable remote causes, and then, 
at some length, the remedial measures which he has found 
most successful. Under this head, Dr. Flint advises the use 
of counter-irritants to the spine, especially capping, and 
generally without scarification. Issues he found inapplica- 
ble, death ensuing in the one case in which he used them. 
There is no doubt, however, that in this instance he had an 
organic disease to deal with, and that the issues had nothing 
to do with the fatal result. Tonics, especially iron, he found 
to be of great advantage. 

1 Abhandlung iiber spinal Irritation, u. s. w. Wien., 1843. 

2 Observations on the Pathological Relations of the Medulla Spinalis. Amer- 
ican Journal of the Medical Sciences, April, 1844, p. 269. 



406 DISEASES OF THE SPINAL COED. 

In a very full analysis of the medical reports of the 
Stockholm Hospital, by Dr. Magnus Huss, 1 the subject of 
spinal irritation receives due consideration. Dr. Huss class- 
es the symptoms of the disorder as follows : 1. Pain of 
various parts of the vertebral column, existing either idio- 
pathically or developed by pressure. 2. Cramps, either of 
a clonic or tonic nature, in those parts subjected to the in- 
fluence of the spinal cord. 3. Loss of power in the same 
portions of the body, ranging from simple stiffness and 
weakness to complete paralysis. 4. Altered sensibility, 
either by excess or by great diminution of sensation. 

It will be observed that in this enumeration the author 
confines his specification of morbid phenomena to those 
which relate to sensation and the power of motion. 

The treatment is fully and philosophically considered. 
Of external remedies he prefers counter-irritants, using the 
milder forms first, and then the severer, such as the moxa 
and the actual cautery, should the first fail. Yenesection, 
either general or local, should be cautiously employed, and 
is not generally indicated. He is the first, so far as my re- 
searches extend, to mention electricity, a means which he 
thinks may be employed with advantage in chronic and de- 
bilitated cases. Potash-baths are also recommended. 

Of internal remedies he specifies iron, opium, strychnia, 
phosphorus, and valerian, as being preeminently useful. 

Axenfeld a devotes a considerable portion of his treatise 
to spinal irritation. He regards it as being produced either 
by a trouble of innervation or congestion. In the treatment, 
leeches occupy the first place, and in light cases blisters, 
sinapisms, dry cups, and stimulating frictions, are useful. 
Internally he recommends nothing but quinine and iron. 

Dr. Radcliffe 3 writes very sensibly on the subject of 
spinal irritation, and gives a typical case which is quite in- 

1 British and Foreign Medical Review, October, 1846, p. 463. 

2 Des Nevroses, Paris, 1863, p. 284. 

3 Reynolds's System of Medicine, London, 1868, vol. ii., p. 640. 



SPINAL ANEMIA, ETC. 4-07 

structive. He incidentally gives it as his opinion, that the 
pathological condition is one of anaemia, and he consequent- 
ly discourages the use of leeches, relying mainly on blisters 
and tonics. 

I have thus cited the principal authorities upon spinal 
irritation, without, however, by any means, exhausting tne 
bibliography of the subject. Notwithstanding the eminence 
of many of those who have contended for the existence of a 
definite affection of the spinal cord, characterized by tender- 
ness on pressure over one or more of the vertebrae, and cer- 
tain eccentric disorders involving sensibility, the power of 
motion, and functional derangement of many of the viscera, 
it must be confessed that the great mass of the medical pro- 
fession has regarded the whole theory with suspicion, if not 
with absolute distrust. The principal reason for this is un- 
doubtedly to be found in the fact that, like many other new 
theories, that of spinal irritation has been applied to explain 
conditions which it could not logically be made to cover. 
Thus many cases of disease or disorder of the heart, due to 
organic difficulties of that organ, or excited by disease of 
other viscera through the sympathetic system, have been at- 
tributed to spinal irritation. The same is true also of the 
uterus, stomach, liver, and other organs, and even of the 
spinal cord itself, which often, when the seat of organic dis- 
eases, such as congestion, meningitis, inflammation, tumors, 
etc., has been regarded as simply in a state of irritation. It 
is very certain, also, that numberless cases of hysteria have 
been attributed to irritation of the spinal cord. In the fol- 
lowing remarks I will endeavor to be as explicit as possible, 
and not to claim too much for a pathological condition 
which I am very sure exists, and which I therefore think is 
entitled to recognition. If I contribute any additional in- 
formation, it will be mainly due to the fact that our means 
of examination are much more perfect and extensive, and 
our knowledge of physiology, pathology, and therapeutics, 



408 DISEASES OF THE SPINAL CORD. 

more thorough than when most of the authors I have quoted 
wrote upon the subject. My observations are based upon a 
careful study of one hundred and twenty-seven cases which 
have occurred in my private practice during the last six 
years, and of which I have full notes, and twenty-nine cases 
of which I have less complete data — in all, one hundred and 
fifty-six cases. 

Symptoms. — Centric Symptoms. — 1. Tenderness at some 
one or more Points over the Spinal Column , increased by 
Pressure. — This is the essential symptom of spinal irrita- 
tion, though varying in intensity from the slight degree of 
pain experienced upon strong pressure to the acute hyper- 
esthesia, which does not allow of even the contact of the 
clothing without the production of great suffering. It is 
generally complained of by the patient, though occasionally 
it has to be sought for by the physician. The brothers Grif- 
fin found this symptom present in all but five out of one 
hundred and forty-eight cases, and it is very probable that 
these five were not cases of spinal irritation, a supposition 
which the authors themselves evidently entertain. Certain- 
ly the details of the cases do not support the view which 
would ascribe their phenomena to any affection of the spinal 
cord. Most of the other authors I have cited refer to this 
tenderness as a prominent feature. Parish thinks it alone 
is to be relied upon as indicating irritation ; Mr. Wliatton 
declares that it is never wanting ; Axenfeld regards it as the 
dominan t and characteristic symptom ; and Radcliffe, while 
admitting that it is not equally well marked in every case, 
states the rule to be that spinal tenderness and spinal irri- 
tation go together. 

On the other hand, Flint does not regard tenderness as 
an invariable and essential element of the affection under 
consideration. He found it absent or indistinct in five of his 
fifty-eight cases, while the other attendant circumstances 
furnished unequivocal evidence that the diagnosis was cor- 
rect. 



SPINAL ANEMIA, ETC. 409 

My own opinion would lead me to consider no case as 
one of spinal irritation in which tenderness on pressure over 
the vertebrae was absent. In the one hundred and twelve 
cases noted by me, this symptom was present in all. There 
are diseases of the spinal cord, which produce derangements 
of other organs of the body, and which are not characterized 
by vertebral tenderness, but these are far more serious af- 
fections than spinal irritation, and of altogether different 
pathology. 

The seat of the tenderness is generally in the dorsal re- 
gion of the spine. The Griffins found cervical tenderness 
in twenty-three cases, cervical and dorsal tenderness in 
forty-six, dorsal alone in twenty-three, dorsal and lumbar 
in fifteen, lumbar in thirteen, the whole spine tender in 
twenty-three, and no tenderness in five. Of one hundred 
and forty-eight cases, therefore, one hundred and seven 
exhibited tenderness in the dorsal region. 

Dr. Flint found cervical and dorsal tenderness in three 
cases, lumbar and dorsal in ten, and dorsal alone in twenty- 
one cases. 

Of my own cases, twenty-five had cervical tenderness 
only, thirty-seven cervical and dorsal, forty-five dorsal only, 
nineteen dorsal and lumbar, fifteen lumbar only, and in fif- 
teen the whole spine was tender. One hundred and sixteen 
cases, therefore, of one hundred and fifty-six were character- 
ized by dorsal tenderness, and in forty-five it was limited to 
this region. 

The degree and character of the tenderness are subject 
to great variation. In some cases strong pressure is required 
to develop it, while in others the least touch is insupport- 
able. Sometimes there are shooting pains, which radiate 
from the tender spot, while at others the hyperesthesia is 
quite circumscribed. In a gentleman now under my care 
with well-marked spinal irritation, and who has a tender 
spot over the third lumbar vertebra, pressure not only causes 
intense suffering at that point, but develops pain along the 



410 DISEASES OF THE SPINAL CORD. 

whole course of the crural nerves and their branches as far 
as their terminations on the inner sides of the feet. An- 
other, a lady, who has spinal tenderness over the eighth cer- 
vical and first dorsal vertebrae, experiences, from pressure, 
intense pain along the course of the first intercostal, the in- 
ternal anterior thoracic, and all the nerves of the left upper 
extremity. Why in these and other cases particular nerves 
should be affected, is a question which will be more fully 
considered hereafter. 

The pain developed by pressure is not always of the same 
character. Sometimes it is dull and aching, and at others 
sharp and lancinating. I have not noticed that any very 
definite relation exists between the character of the pain and 
the severity of the other symptoms, though, as regards the 
degree of pain of each kind, there is a marked connection. 
By this I mean that a dull, aching sensation may indicate 
as profound a pathological condition, and be accompanied 
by as intense eccentric phenomena, as a sharp and lanci- 
nating pain, though a severe aching pain and a severe lan- 
cinating pain always indicate more serious disorder than 
when these sensations are not so emphatic. 

The character of the pain varies in accordance with the 
tissue in which it is felt. The dull aching sensation is only 
developed by strong pressure, and is seated in the muscular, 
tendinous, or cartilaginous structures about the vertebrae. 
The sharp, piercing twinges excited by slight pressure arise 
from the skin, and subcutaneous cellular tissue. With 
these species of sensations, the aesthesiometer always shows 
increased sensibility of the skin over and in the vicinity of 
the painful centres. 

To ascertain whether or not the tissues outside of the 
spinal canal are in a state of hyperaesthesia, the pressure 
should be applied with gradually-increasing force, by means 
of the thumbs applied to the spinous processes and the in- 
tervertebral spaces, as recommended by Flint. The exami- 
nation should be thorough, and extend throughout the 



SPIXAL ANEMIA, ETC. 411 

whole extent of the vertebral column. The fact that the 
patient denies the existence of tenderness should have no 
weight with the physician. Only a few days ago a young 
lady consulted me for severe infra-mammary pain, headache, 
and nausea. I at once suspected spinal irritation, but she 
declared, in answer to my inquiries, that there was no sign 
of tenderness anywhere over the spinal column. I insisted, 
however, on a manual examination, and to her great sur- 
prise found three spots that were exceedingly painful to 
slight pressure. This young lady had been treated for 
dyspepsia for several years, without deriving any benefit 
from the measures used, but was cured by the treatment 
which I shall presently fully consider. Occasionally it 
happens that the tenderness is not perceived for some time 
after the pressure is made. In a recent case I found the 
interval to be over a minute, and then acute pain, following 
ing the course of the nerves, was experienced. I am not 
prepared to offer an explanation of this phenomenon. 

2. Pain in the Spinal Cord. — The tenderness just no- 
ticed is seated primarily externally to the vertebral canal, 
and is developed by pressure. That which is now to be 
considered is located in the spinal cord, and is, therefore, 
capable of being produced by pressure upon non-tender 
spots. It is a very common symptom, having been present 
in one hundred and one of my cases. Generally it is con- 
founded with spinal tenderness, from which, however, it is 
quite distinct. It is aggravated by motion of the spinal 
column, by action of the muscles which have their attach- 
ments to the spinous and transverse processes, by percussion, 
and sometimes by the erect posture. In the case of a gen- 
tleman of this city, it was so great when he stood up that 
he was forced to keep the recumbent position nearly the 
whole time. "When I first saw him he was wearing an 
apparatus designed to keep the weight of the head from the 
vertebral column, and to prevent the vertebrae pressing upon 
each other, under the idea that he had disease of the inter- 



412 DISEASES OF THE SPINAL CORD. 

vertebral substance. I removed the instrument, and, treat- 
ing him for spinal irritation, he recovered his health in a 
few weeks. 

Pain in the spinal cord, in the disorder under consider- 
ation, is usually seated near the point of external tender- 
ness, though it is often at a distance, and sometimes is felt 
throughout the whole extent of the cord. The eccentric 
phenomena bear a distinct anatomical and physiological re- 
lation to it, as do those which are connected with spinal 
tenderness. There is likewise a similar connection existing 
between the pain in the cord and the vertebral tenderness. 

To ascertain the existence of spinal pain, when it is not 
spontaneously felt or superinduced by muscular exertion, 
percussion should be practised. The ends of the fingers 
will answer for this purpose, though I prefer a little vul- 
canized india-rubber hammer, and a plessimeter, such as are 
sometimes used for percussing the chest. Even over spots 
which exhibit much tenderness, the deep-seated pain in the 
cord itself can clearly be distinguished. 

Eccentric Symptoms. — By far the most important and 
noticeable symptoms of spinal irritation are to be found in 
distant parts of the body. These vary in their character 
and seat, according to the part of the spinal cord affected. 
Following the example of the Griffins, I shall consider these 
symptoms as they depend upon irritation of the several re- 
gions of the cord with which they are connected. 

a. The Cervical Region. — Of the cases upon which this 
.paper is based, in twenty-five the irritation existed in the 
cervical region only, of .the spinal cord ; in thirty-seven, the 
cervical tenderness was conjoined with dorsal tenderness, 
and in fifteen with tenderness of the whole spine. Taking 
the uncomplicated cases as presenting the clearest features, 
the following would appear to be the more prominent symp- 
toms of cervical spinal irritation. 

Vertigo was an accompaniment in eleven cases, and 
headache in fifteen ; noises in the ears in eight, and disturb- 



SPINAL ANAEMIA, ETC. 413 

ances of vision in four, fulness and a sense of constric- 
tion across the forehead were complained of in several cases, 
as was also tenderness of the scalp. In addition, the mind 
was more or less affected in every case, and in seven the 
aberration was of such a character as almost to amount to 
insanity. In one of these, a married lady, aged thirty, 
there were several paroxysms of maniacal excitement 
every day ; and in another, that of a young lady aged 
twenty-three, so furious were the exacerbations that, for 
fear she would injure herself or others, she had to be re- 
strained by two strong nurses, who held her while the fits 
lasted. The predominant type, however, was melancholia. 

Sleep was deranged in every case, generally in the form 
of insomnia, though in three cases the tendency to somno- 
lence was excessive. In every case the dreams were of an 
unpleasant character ; in two there was nightmare, and in 
one somnambulism. 

Neuralgic pains were present in seventeen of the twenty- 
five cases. If the upper part of the cervical region was the 
seat of the irritation, these pains were experienced in the 
scalp and face ; if the lower, they were seated in the neck, 
the shoulders, upper part of the chest, and the upper extremi- 
ties. Sometimes the pain was of a dull-, burning character, 
and was then generally seated in the muscles of the nucha. 
Muscular effort always increased the suffering. In accord- 
ance with Teale's experience, it several times occurred that 
the neuralgia was intermittent, the paroxysms coming on 
about sundown and lasting through the night. In none of 
these cases was there ansesthesia. 

Motility was interfered with in eighteen cases. Some- 
times there were fibrillary twitching s ; in five cases there 
were clonic spasms of the muscles of the face and neck ; in 
three, general chorea ; in two, contractions of the flexors of 
the arm on one side, so that the elbow was rigidly bent ; in 
two, the contractions were in the flexors of the hands, and 
in four, of the lingers. In one case there was complete loss 



414 DISEASES OF THE SPINAL CORD. 

of power over the hand ; in four, aphonia ; and in one, 
almost constant hiccough while the patient was awake. 

Nausea was present more or less in fifteen cases, and, in 
one, part of every thing taken into the stomach was almost 
immediately rejected. Pain in the stomach was not met 
with in any case. 

b. The Dorsal Region. — I found the dorsal region of the 
spine tender in one hundred and sixteen cases. In thirty- 
seven of these it was conjoined with cervical, in nineteen 
with lumbar tenderness, and in fifteen it was affected with 
the whole spine, leaving forty-five uncomplicated cases. 

The most prominent symptoms in these cases were con- 
nected with the viscera, the stomach being the organ com- 
monly involved. Thus, gastralgia was present in every 
case, nausea and vomiting in nine cases, pyrosis in three, 
gastric flatulence in forty, and acidity, as evidenced by 
heartburn, in twenty-six. 

Next in order came the heart. There w ere palpitations 
in twenty- six cases, fits of oppression, during which the 
heart beat with irregularity as regarded force and rhythm, 
in ten cases, and attacks of syncope in five. 

There was difficulty of breathing in fifteen cases, and 
cough in fifteen. 

Intercostal neuralgia existed in ten, and infra-mam- 
mary pain in thirty-one cases. 

There were no muscular spasms, contractions, or paraly- 
sis. 

In the thirty-seven cases in which the dorsal tenderness 
was conjoined with cervical tenderness, the symptoms char- 
acteristic of each region were more or less intermingled. 
In two cases there was epilepsy, and in three chorea para- 
lytica. 

c. The Lumbar Region. — This portion of the spine ex- 
hibited tenderness in forty-nine cases. In nineteen of these 
it was accompanied by dorsal tenderness, in fifteen the 
whole spine was affected, and in fifteen the tenderness was 



SPINAL ANAEMIA, ETC. 415 

confined to the lumbar region alone. Of these latter all 
were characterized by neuralgic pains in the lower extremi- 
ties, and in three of them there were similar pains in the mus- 
cles of the back and abdomen. In six there was spasm of 
the neck of the Madder, accompanied with severe pain, and 
causing great difficulty of urinating, in one there was in- 
continence of urine, in five pain in the uterus and ovaries, 
and in one neuralgia of the rectum. 

Motility was affected in eight cases. In four of these 
there were strong tonic contractions of the muscles of the 
lower extremities, and in four paralysis. In all of these 
there were occasional clonic spasms simulating chorea. Of 
the nineteen cases in which there was also dorsal tender- 
ness, the symptoms were in general those characteristic of 
spinal irritation of both regions. 

d. The whole spine was tender in fifteen cases, and so 
extensive was the hyperesthesia that it was scarcely pos- 
sible to press upon the most limited spot without producing 
pain. Of these cases the most prominent symptom in three 
was epilepsy, in one paralysis, sometimes of the upper and 
sometimes of the lower extremities, and in three contrac- 
tions of the limbs. Neuralgic pains, either in the scalp, 
face, neck, chest, upper extremities, abdomen, and lower 
extremities, were present in every case, according to the 
part most severely affected for the time being. The 
heart was disordered in five cases, the stomach in ten, in 
three there was difficulty of swallowing, from alternating 
paralysis, and spasm of the muscles of the larynx, and in 
two aphonia. 

Causes. — The most powerful predisposing cause is sex. 
Of the one hundred and fifty-six cases, one hundred and 
forty were females. Age is likewise influential in deter- 
mining to the disorder. Of one hundred and thirty-seven 
cases in which I have recorded the age, seventy-two were 
between fifteen and twenty-five, thirty-two between twenty- 
five and thirty-five, fifteen under fifteen, and eighteen over 



416 DISEASES OF THE SPINAL CORD. 

thirty-five. The period of life between fifteen and twenty- 
five is therefore that at which spinal irritation is most apt 
to occur. 

Hereditary influence was ascertained to exist in thirty 
cases. 

The exciting cause of spinal irritation is not always easy 
to ascertain. In thirty out of one hundred and thirty-seven 
cases I could not, by the most careful inquiry, find any cir- 
cumstance likely to have given it origin. In twenty-one it 
was manifestly produced by blows, falls, or strains, in twelve 
it was obviously caused by sexual excesses, and four by 
onanism. In ten there was reason to ascribe it to anxiety 
and grief, in two to excessive mental exertion, in twenty- 
one to insufficient physical exercise, in fourteen to innu- 
tritious and insufficient food, in three to over-indulgence in 
alcoholic liquors, and in one to the use of opium. In the 
remaining nineteen cases it followed exhausting diseases, 
such as typhoid, scarlet, and intermittent fever, dysentery, 
and diphtheria, and was probably directly the result of 
their influence. 

It may also be caused by obliteration of the aorta or 
spinal vessels, by tumors, thrombosis, or embolism, by 
haemorrhage from vessels in relation with those of the cord, 
or by exposure to severe cold. 

In general terms, it may be said that any cause capable 
of reducing the powers of the system may produce spinal 
irritation. 

Morbid Anatomy and Pathology. — I have already stated it 
as my opinion that the essential condition of spinal irritation 
is ansemia of the posterior columns of the cord. Other writers 
have ascribed it to inflammation, congestion, hysteria, and 
numerous other factors. The reasons which have induced 
me to arrive at this conclusion are briefly as follows : Owing 
to the fact that spinal irritation is not per se a fatal disease, 
we rarely have the opportunity to verify any views we may 
hold in regard to its pathology. In the few cases in which 



SPINAL ANEMIA, ETC. 417 

post-mortem examinations were made, nothing abnormal 
was found, a circumstance, however, far more compatible 
with the idea I have expressed than with any other : 

1. It is a well-recognized fact that irritation is often a 
result of a deficient supply or a poor quality of blood. Thus 
headaches are frequently caused by cerebral anaemia, and 
are promptly relieved by increasing the amount of blood in 
the cerebral blood-vessels. Irritability of the mind is also a 
constant accompaniment. A feebly-nourished stomach re- 
jects food, and is the seat of pain. An anaemic heart beats 
with great rapidity, weak muscles are affected with tremor, 
and an exhausted generative system is brought into a state 
of unnatural erethism by the slightest kind of excitation. 
Analogy, therefore, supports the theory I have suggested. 

2. The diagnosis of diseases of the spinal cord has be- 
come so perfect that we are able to distinguish congestion, 
meningitis, myelitis, softening, tumors, etc., by their symp- 
toms and by the means of research at our command. We 
see, therefore, that the morbid phenomena which result from 
such conditions are not such as we now class under the head 
of spinal irritation. This division of the subject will be 
more fully considered under the head of diagnosis. 

3. I have repeatedly ascertained, by actual experience, 
that those agents which are known to diminish the amount 
of blood in the spinal vessels invariably increase the severity 
of the symptoms due to spinal irritation, while they are as 
effectually lessened in intensity by remedies which tend to 
produce spinal hyperemia. 

4. The general condition of patients the subjects of spi- 
nal irritation is always below par, and the exciting causes 
are all such as tend to the production of asthenia. 

5. The character of the symptoms points decidedly to 
the greater, and at times sole implication of the posterior 
columns. There are cases of the disorder in which there is 
no derangement of motility in any part of the body, and in 
all cases aberrations of sensibility are the prominent fea- 

27 



418 DISEASES OF THE SPINAL CORD. 

tures. Moreover, the viscera are generally affected in their 
functions, a circumstance of itself strongly indicative of the 
situation of the lesion in the posterior columns. 

These circumstances, I think, go very far toward con- 
firming the view I have expressed, that in spinal irritation 
the vessels of the cord, especially those of the posterior col- 
umns, contain less blood, and that this fluid is inferior in 
quality to that when the organ is in a healthy condition. 
Now that the function of the sympathetic nerve, as regards 
its action in regulating the calibre of the blood-vessels, is so 
satisfactorily proven, we can partially understand how local 
congestions and anaemias may be superinduced. It is prob- 
able, therefore, that the original difficulty in many cases of 
spinal irritation resides in the sympathetic system, and the 
intimate anatomical relations existing between the two ner- 
vous centres are strongly in favor of this suggestion. 

On the other hand, many of the phenomena of spinal 
irritation point strongly to the secondary involvement of the 
sympathetic system. It is thus that the visceral disturb- 
ances which form such prominent features are mainly to be 
explained. 

The pathology of several others of the more striking 
symptoms of spinal irritation has been a subject of frequent 
discussion, but at the present day presents no difficulties. 
Thus the excitation of pain in the tissues to which the cuta- 
neous nerves are distributed results from the law that irri- 
tation at a nervous centre induces pain at the points in 
which the nerves arising from that centre end. Each com- 
pound spinal nerve sends a twig to the skin contiguous to 
it, and these twigs terminate immediately over the spinous 
processes. Now, whenever an irritation is thus transmitted 
to the periphery, it may be reflected back to the centre 
whence it came, by local irritations. Thus a patient is suf- 
fering from chronic inflammation of the spinal cord, and in 
consequence has pain and muscular spasms in his lower ex- 
tremities. An irritation applied directly to the cord in- 



SPINAL ANEMIA, ETC. 419 

creases the pain and spasms ; an irritation applied to the 
lower extremities augments the pain in the cord, and may 
induce pain and spasms in distant parts of the body. Hence 
it is that pressure on the skin over the spinous processes not 
only causes cutaneous pain, but also gives rise to spinal pain, 
and neuralgic sensations in those nerves which come from 
the irritated part of the cord. 

The pain existing in the cord is aggravated by percus- 
sion or muscular action. The spinal cord, it is true, is en- 
closed in a stroijg and thick, bony canal, which, however, 
is entirely filled by its contents. A blow, therefore, on the 
exterior of the column causes a vibration, which is propa- 
gated through the bony structure to the cord and its mem- 
branes. If this blow be very violent, the concussion may 
be such as to inflict irreparable damage on the cord. When 
any portion of the cord is in a state of irritation, a very light 
blow upon the spinous processes, over the disordered part, 
will cause severe pain, or notably add to that already pres- 
ent. The vertebral column is flexible, aud therefore mus- 
cular action may, by producing deviations from the ordinary 
line followed, occasion pressure, and, in the abnormal con- 
dition of the cord, excite pain. 

Diagnosis. — Recollecting that no case is to be regarded 
as one of spinal irritation which is not characterized by 
spinal tenderness, we have our diagnostic inquiries limited 
to the distinguishing of spinal irritation from other spinal 
affections. It is certainly true that the distinction has often 
been overlooked, and that at times there is a real difficulty 
in forming a correct judgment. Nevertheless, by carefully 
estimating all the circumstances, permanent errors of diag- 
nosis are not likely to occur. 

There are three diseases of the spinal cord which may 
in their earlier stages be confounded with simple spinal irri- 
tation. These are chronic myelitis, meningitis, and con- 
gestion. As the treatment of these affections is in many 
respects the exact reverse of that proper for spinal irritation, 



420 DISEASES OF THE SPINAL CORD. 

and as they are of far more serious character, it is impor- 
tant to make as early and as correct a discrimination as pos- 
sible. 

In both spinal irritation and myelitis there is tenderness 
over some part of the vertebral column, which tenderness is 
increased by pressure, but this tenderness is never due to 
hyperesthesia of the skin, whereas in spinal irritation it 
often is. 

In spinal irritation there is never, so far as my experience 
goes, anaesthesia, whereas this is a constant accompaniment 
of myelitis. 

The contractions which take place in some cases of spi- 
nal irritation are painless, while those due to myelitis are 
attended with great suffering. 

In myelitis there is a sensation as if a tight cord were 
tied around the body at the upper limit of the paralysis, a 
sensation which is absent in spinal irritation. It is true 
that Mr. Teale has described several cases which he classed 
as spinal irritation and in which the sensation of constric- 
tion was present, but careful examination of the histories 
leaves scarcely a doubt that these were really cases of mye- 
litis. 

The bladder is never paralyzed in spinal irritation, 
whereas in myelitis it generally is, if the inflammation be 
located in the lower dorsal region of the cord. The same is 
true of the sphincter ani. Myelitis is always productive of 
paralysis, and there is always more or less atrophy of the 
paralyzed muscles. Spinal irritation seldom gives rise to 
paralysis, which, when it does result, is always incomplete, 
and is never productive of atrophy. 

The progress of myelitis is generally, unless arrested by 
appropriate treatment, toward a worse condition, whereas 
no such tendency is manifested by spinal irritation. 

From spinal meningitis, spinal irritation is distinguished 
by the circumstances that in the former disease there are 
constant painful spasms of the muscles of the back, pain 



SPINAL ANAEMIA, ETC. 421 

in the cord, and no spinal tenderness increased by pres- 
sure. 

From congestion of the spinal cord and its membranes, 
spinal irritation is sufficiently distinguished by the facts that 
there is generally little or no pain in the cord in the first- 
named affection, and no spinal tenderness. In congestion, 
likewise, the paralysis and other symptoms are always worse 
after the patient has been lying down, while in spinal irrita- 
tion the recumbent position always alleviates the condition. 

Another means, which in doubtful cases will invariably 
lead to a correct diagnosis, is afforded by the known effects 
of certain medicines. Thus spinal irritation is, as I have 
several times ascertained, made worse by the administration 
of ergot, while each one of the other diseases I have named 
is alleviated. The reverse is true of strychnia, which in all 
cases aggravates the symptoms of myelitis, meningitis, or 
congestion, while it is an efficient means of cure in spinal 
irritation. A hypodermic injection of the thirtieth of a 
grain is sufficient to settle the matter in cases where the 
diagnosis is of difficult formation. 

The flatulence, eructations, and vomiting, are very symp- 
tomatic of spinal irritation, while they are rarely phenom- 
ena of either of the other affections. 

One other disease is liable to be confounded with spinal 
irritation, and that is angular curvature, in which there is 
spinal tenderness increased by pressure. The facts, how- 
ever, that strumous disease of the vertebras generally occurs 
in children, that the scrofulous diathesis is always present, 
that an angular prominence can be detected by careful ex- 
amination, that the paralysis progressively becomes more 
profound, that the constitutional effects are more severe, are 
sufficient, even in doubtful cases, to guide to a correct diag- 
nosis. 

Prognosis. — The prognosis in cases of spinal irritation is 
generally favorable. In fact, so far as my experience ex- 
tends, I have never seen a case which entirely resisted treat- 



422 DISEASES OF THE SPINAL CORD. 

ment, and very few in which a cure was not ultimately 
effected. When remedies suitable for the difficulty do not 
prove successful, it is because the patient does not stead- 
fastly persevere in their use. 

Of the one hundred and fifty-six cases forming the basis 
of this chapter, one hundred and thirty-three were thorough- 
ly cured, ten were lost sight of soon after treatment was 
commenced, but were materially improved, and thirteen 
were relieved for the time being, but continued to have re- 
lapses. 

Treatment.— The principles of treatment applicable to 
spinal irritation are four : 

1. To remove the cause. 

2. To improve the general tone of the system. 

3. To increase the amount of blood in the spinal cord, 
and improve the nutrition of this organ. 

4. To set up a counter-irritant action in the vicinity of 
the disordered region of the cord. 

In regard to the first indication, I have nothing special 
to say. The cause once ascertained, common-sense would 
dictate its removal as speedily and as effectually as possible, 
by the proper means according to its character. 

The second indication is to be met by tonics, such as 
quinine and iron, and especially stimulants judiciously ad- 
ministered. I am as well convinced of the general applica- 
bility of alcohol in some form, in the treatment of spinal 
irritation, as I am of any thing. "Whiskey, brandy, and 
rum, are to be preferred on account of their less liability to 
disagree with the stomach, and as containing a greater per- 
centage of alcohol than vinous or malt liquors. Among the 
tonics the preparations of zinc are valuable, and I think the 
oxide is to be preferred. Cod-liver oil is also of great ser- 
vice. 

The third indication is easily fulfilled by strychnia, phos- 
phorus, phosphoric acid, and opium. The two first-named 
remedies may be very satisfactorily combined in a pill con- 



SPIXAL AX.EMIA, ETC. 423 

taining half a grain of extract of nux-vomica and the tenth 
of a grain of the phosphide of zinc, which may be given 
three times a day. Strychnia may also be given by solution 
of the sulphate in dilute phosphoric acid, and in doses of 
about the thirty-second of a grain to half a drachm of the 
acid. The beneficial effects of these remedies are perceived 
in a few days. Opium is especially useful in those cases in 
which there are contractions of the limbs, and here its ac- 
tion is, of course, not solely that of an agent increasing the 
amount of blood in the cord. I prefer to give it either in 
the form of suppositories, composed each of half a grain of 
the aqueous extract and a sufficient quantity of the butter 
of cacao, or by hypodermic injection of morphia. I have 
frequently seen contractions, which had persisted with obsti- 
nacy for several weeks, relax in a few minutes under the in- 
fluence of opium thus administered. 

The application of hot water to the spine is also an ad- 
mirable adjuvant. It should be used as hot as can be borne. 
Nothing is better for the purpose than Dr. Chapman's india- 
rubber bags. 

But there is a remedy which apparently either contracts 
or enlarges the diameter of the blood-vessels, and which is 
more efficacious in removing spinal irritation than any other 
with which I am acquainted, and that is the direct galvanic 
current. The method I follow in cases of spinal irritation 
is the application of the negative pole at some point above 
the seat of the pain, and the positive at another, an equal 
distance below. An ascending current is thus brought to 
bear upon the cord, and this seemingly conduces to the dila- 
tation of the blood-vessels and the improvement of the nu- 
trition of the cord. The current should not be passed at 
any one seance for more than fifteen minutes, and no one 
application should last longer than three or four minutes. 
For the relief of the spinal tenderness the negative pole 
should be applied directly to the painful part, and the posi- 
tive to a point distant laterally from it a few inches. 



424 DISEASES OF THE SPINAL CORD. 

In inflammation or congestion of the cord or its menin- 
ges, the method of application is directly the reverse of 
this. 

The fourth indication is one of great importance, and, 
when properly carried into effect, a cnre will often result in 
slight cases without any other means of treatment being 
employed. The rationale of the action of counter-irritants 
in this and similar derangements is by no means clearly un- 
derstood. It is a question which I do not, however, propose 
to discuss. Of counter-irritants my experience leads me de- 
cidedly to the employment of blisters in preference to any 
others. They should be applied to the skin, immediately 
over the painful part of the spine, and should be renewed 
as often as may be necessary. Tartar-emetic ointment, 
though useful, is more painful and I think not so efficacious 
as blisters. Dry cups are more admissible, and almost al- 
ways do good. They should be applied on each side of the 
spinous processes for an extent of four or £.ve inches above 
and below the painful spot. Leeches, or any other means 
for the abstraction of blood are, according to my experience, 
always prejudicial. 

Besides these therapeutical means, there are others of a 
more strictly hygienic character, which cannot be over- 
looked. Thus the food should be of a highly-nutritious 
character, moderate physical exercise should be taken, and 
as much time as possible should be spent in the open air. 

Patients almost always feel more comfortable in the re- 
cumbent position than any other, because thereby the blood 
is allowed to settle in the spinal vessels. They should not 
therefore be prevented lying down during the greater part 
of the day, but at the same time they should be encouraged 
to take exercise, and especially so when there is any loss of 
power in the lower extremities. The induced or faradaic 
current is almost always of service, when applied to the 
affected muscles, and the direct is of great efficacy when 
passed through neuralgic nervous trunks. 



SPINAL ANJEMIA, ETC. 425 

In illustration of the views inculcated in this memoir, I 
append the following details of cases : 

Case I. Irritation of the Cervical Region of the Spinal 
Cord. — Mrs. J. S. consulted me, May 7, 1868, for what she 
had been informed was a cerebral disorder. The patient 
was thirty-eight years of age, had had five children, and 
had always enjoyed good health till two years previously, 
when she had been thrown from her carriage. She was not 
stunned or otherwise seriously injured. Soon after the acci- 
dent she noticed a rumbling noise in one ear, and in a few 
days subsequently the other ear became similarly affected. 
About the same time there were flashes of light before the 
eyes, and a dull, heavy pain in this point of the head. Ver- 
tigo was also frequently present. There was insomnia, and 
when she did sleep she was very apt to be attacked with 
nightmare. 

These symptoms continued to annoy her for several 
months, without, however, compelling her to seek for medi- 
cal advice, until at last she had a seizure which was certainly 
epileptic in its character. This was followed with disturb- 
ance of vision, and intense neuralgia of the fifth pair of 
nerves. She now placed herself under the charge of a phy- 
sician in a neighboring city, where she was then residing, 
who diagnosed a tumor of the brain, and gave an unfavor- 
able opinion as to the ultimate result. He, however, ad- 
vised the use of iodide of potassium. She took this in large 
doses faithfully for three months — during which period she 
had two more epileptic attacks — without perceiving any 
benefit, and then she went to Europe. While there she 
consulted a number of physicians and surgeons of eminence, 
all of whom gave a very guarded prognosis. By the advice 
of several of these she took the bromide of potassium, with, 
at first, some advantage, but this was eventually lost, and 
her symptoms became as severe as before. She had several 
epileptic paroxysms during the four months she was taking 
the bromide. Finally, she travelled through Germany and 



426 DISEASES OF THE SPINAL CORD. 

Italy, and, still obtaining no relief, returned home. I saw 
her a few days after her arrival. She was then suffering 
from facial neuralgia, excessive tenderness of the scalp, so 
that she could not have her hair brushed without enduring 
great pain, obscureness of vision, pain in the eyeballs, red- 
ness of the conjunctivae, vertigo almost constantly, great 
mental irritability, amounting at times to positive insanity ; 
wakefulness, nightmare, and contraction of the fingers, the 
nails being strongly pressed against the palm of the hand. 

Ophthalmoscopic examination showed dilatation of the 
retinal vessels, arterial and venous pulsation, and congestion 
of the optic disks of both eyes. The pupils of both eyes 
were contracted. 

Perhaps I should not have suspected any spinal diffi- 
culty, if she had not herself called my attention to a pain 
which she said she constantly felt between the shoulders. 
I therefore examined the upper part of the spine very care- 
fully, and found deep-seated pain developed by percussion 
over the seventh cervical vertebra, and great hyperesthesia 
of the skin over the eighth. Her symptoms were not those 
in the least indicative of congestion of the cord or its mem- 
branes, of meningitis, or myelitis, and the apparent severity 
of the cerebral symptoms, and the general good condition 
of her mind and sensorial and motor functions, were so 
incompatible, that I could not, upon reflection, bring myself 
to the belief that she was affected with any organic disease 
of the brain. My inquiries and examinations all led me to 
the conclusion that she was laboring under spinal irritation 
of the lower cervical region. 

I therefore prescribed for her five drops of the phos- 
phorated oil three times a day, applied a blister to the pain- 
ful spot, and daily passed the direct galvanic current through 
the cord, by applying the negative pole to the fifth cervical, 
and the positive to the sixth dorsal. My object was, not 
only to improve the nutrition of the cord, but also, by irri- 
tation of the sympathetic, to contract the vessels of the 



SPINAL ANEMIA, ETC. 427 

brain. Budge and Waller had shown, several years pre- 
viously, that, when that portion of the spinal cord situated 
between the seventh cervical and sixth dorsal vertebrae is 
acted upon by the galvanic current, the pupils are dilated. 
Now, dilatation of the pupils is produced by excitation of 
the sympathetic, and excitation of the sympathetic within 
the limits mentioned likewise causes contraction of the ves- 
sels of the brain, as can readily be seen by ophthalmoscopic 
examination while the current is passing. 

Under the influence of this treatment the amendment 
was rapid, and at the end of three months she was entirely 
cured. It was necessary, however, to apply eleven blisters. 

Case II. Irritation of the Cervical Region of the Cord. 
— M. S., a gentleman of sedentary habits, consulted me, 
August, 1867, for intense headache and facial neuralgia, 
with which he had suffered for several months. The disease 
had come on gradually, and, although now never entirely 
absent, was paroxysmal in its character, being more severe 
at night than through the day. The external pain followed 
the course of the fifth pair of nerves through all its branches ; 
the internal was fixed in the posterior part of the head, and 
was evidently due to cerebral anaemia, as it was relieved by 
stimulants and by holding the head in a dependent position. 
Vertigo was frequently present, and the disposition to sleep 
was excessive, though, owing to the pain, could not be in- 
dulged in for more than a few minutes at a time. Nausea 
was occasionally a symptom, but never to the extent of being 
followed by vomiting. 

On examining the spine of this gentleman, I found ten- 
derness over the fourth and seventh cervical vertebrae. Two 
blisters were at once applied, and Aitken's syrup of the 
phosphate of iron, quinine, and strychnia, administered. 
From the first, improvement was manifested, and in less 
than a month the cure was complete. 

Case III. Irritation of the Dorsal Region of the Spinal 
Cord. — Mrs. J. B., aged twenty-four, consulted me, March, 



428 DISEASES OF THE SPINAL CORD. 

1868, for obstinate vomiting, and neuralgic pains in the left 
breast. She was thin, pale, and anaemic, and had suffered 
for over a year. She also complained of a dull, aching pain 
in the middle of the back, which was increased by even 
moderate physical exercise. The vomiting took place regu- 
larly after every meal, and even water was at once thrown 
up. She was under the impression that the disorder was 
the result of exposure for several hours to very severe cold 
while in an open boat. 

Recognizing, at once, the fact that the main difficulty 
lay in the cord, I carefully examined the whole spine, and 
found excessive tenderness over the spinous processes of the 
sixth, seventh, and eighth dorsal vertebrae. There was also 
deep-seated spinal pain developed by percussion. 

I ordered the application of a blister, and the internal 
use of small quantities, frequently repeated, of milk-punch 
(one ounce of brandy to three of milk). The first wineglass- 
ful was at once rejected, and so was a tablespoonful which 
she took half an hour subsequently. I then reduced the 
quantity to a teaspoonful every half hour. This was re- 
tained, and was the first nutriment of any kind which, for 
nearly eleven months, had not been rejected wholly or in, 
part. 

The next day I found that the blister had drawn well, 
and that the nausea and vomiting were greatly diminished, 
as were likewise the neuralgic pains. A teaspoonful of the 
following mixture was then directed to be taken three times 
a day, immediately after meals: Ipfc. Strychniae sulph. gr. j, 
ferri pyrophosph., quiniae sulph. aa. 3 ss, acid phosph. dil., 
syrupus zingiberis aa. §ij. M. ft. mist. The milk-punch 
was still continued, but, in treble the dose, less frequently 
given. 

Gradually all the symptoms decreased in violence, and 
at the end of two weeks she was enabled to retain a mod- 
erate quantity of food at each meal. Any excess was still, 
however, followed by vomiting. She had increased five 



SPINAL ANEMIA, ETC. 429 

pounds in weight, and was greatly improved in personal 
appearance. 

In two months she had gained twenty-one pounds, and 
was as well as she had ever been in her life. The spinal ten- 
derness had entirely disappeared ; seven blisters were ap- 
plied in all. 

Case IV. Irritation of the Dorsal Region of the Spinal 
Cord. — Mrs. W. had for more than three years suffered from 
spasmodic movements of the upper extremities, not distin- 
guishable from those of true chorea, which occasionally were 
followed by contractions of the flexors of the wrists and fin- 
gers. There were also infra-mammary pain, eructations, 
and vomiting. When she came under my care, June 22, 
1869, she was reduced to almost a skeleton, and was suffer- 
ing, in addition to the symptoms above mentioned, from 
acute pain in the back. This pain she informed me had not 
been ordinarily very severe, but was, nevertheless, constant- 
ly present. On examination I found tenderness over the 
first, second, and third dorsal vertebrae. I at once applied 
the constant galvanic current in the manner already de- 
scribed, and continued it for live minutes, with the effect of 
mitigating the pain in the spine and the nausea. The en- 
suing day I repeated the application, and in addition pre- 
scribed the mixture given in Case III. She retained it on 
her stomach, as she did the food which she ate that day. 
Brandy in ounce-doses was given with her lunch and dinner. 
The galvanism was continued daily for eighteen days, at the 
end of which time she was free from pain, from the spasms, 
and from the vomiting. Her appearance was immensely 
improved, and she had increased seven pounds in weight. 
The galvanism was now discontinued, but the strychnia 
mixture and the brandy were persevered with for over a 
month longer. She was then well. 

Case Y. Irritation of the lumbar Region of the Spinal 
Cord. — E. T., an unmarried lady, aged twenty-nine, con- 
sulted me, August, 1869, for paralysis of the lower extremi- 



430 DISEASES OF THE SPINAL CORD. 

ties, attended with spinal tenderness and abdominal pains. 
She had been treated for inflammation of the spinal cord, 
had been cupped, leeched, and had had an issue made over 
the seat of the pain. 

When I first saw her she was unable to walk, having 
been in this condition for several months. As she sat in her 
chair, she could readily move her legs in any desired direc- 
tion, but to bear her weight upon them was an utter im- 
possibility. There was no alteration of sensibility. Her 
general appearance was not anaemic, nor was she in the 
least degree hysterical. Upon careful examination, I was 
unable to find any reason to induce the belief that she was 
laboring under spinal congestion, meningitis, or myelitis, 
or that there was softening of, or pressure upon, the cord. 
I, however, discovered great tenderness over the first and 
second lumbar vertebrae, and found that strong pressure in 
this region induced deep-seated spinal pain and sharp neu- 
ralgic sensations along the course of the crural nerves. 

Regarding the case as one of pure spinal irritation, I ap- 
plied the constant galvanic current to the back every alter- 
nate day, and administered the following prescription : I-L 
Zinci phosphidi, grs. iij, ext. nucis vom. grs. xv. M. ft. in 
pil. no. xxx. Dose, one three times a day. I likewise di- 
rected the application, to the painful part of the spine, of 
flannel, wrung out of spirits of turpentine, to be continued 
daily till redness and decided smarting were produced. A 
full and nutritious diet, with ale, was enjoined. Under this 
treatment she improved so rapidly in every respect that in 
twenty-three days she was able to walk with a cane, and in 
a few days more than a month was well, being in as good 
health, according to her own report, as she had ever enjoyed 
in her life. 

ANAEMIA OF THE ANTEEO-LATEEAL COLUMN'S OF THE COED. 

The phenomena which in my opinion are the result of an 
anaemic condition of the antero-lateral columns of the spinal 



SPINAL ANEMIA, ETC. 431 

cord have hitherto been classed under the heads of spinal 
paresis, functional paralysis, reflex paralysis, inhibitory pa- 
ralysis, paralysis from peripheral irritation, etc. Several of 
these names are applied with reference to the causes, others 
with reference to the symptoms, but none to the lesion. 

Symptoms. — The most prominent symptom of anaemia of 
the antero-lateral columns of the spinal cord is paralysis of 
motion in those parts of the body which derive their nerves 
from the affected portion of the cord, and in many cases of 
those below the seat of the lesion. This paralysis is incom- 
plete, the patient, if the lower extremities are affected, being 
able to walk, though he does so with difficulty. It is no- 
ticed, too, that some muscles are more apt to be paralyzed 
than others, the tibialis anticus and the peroneal group 
rarely escaping. 

In the great majority of cases the paralysis is confined to 
the lower extremities, constituting paraplegia. The reason 
for this is, that the anaemic condition of the cord which 
causes the paralysis is more frequently excited by irritation 
transmitted from the genito- urinary and digestive organs 
than from any others. 

Spasmodic contractions of the paralyzed muscles are not 
often met with, though occasionally there are slight twitch- 
ings, fibrillary in their character. 

It is rarely the case that the paralysis extends, as it does 
in that which results from congestion of the cord. The af- 
fection usually supervenes suddenly, and is about as severe 
in the beginning as at any subsequent period. 

The bladder and rectum are very rarely involved as a 
consequence of the spinal lesion, though disease of either 
of these organs often causes anaemia of the antero-lateral 
columns of the cord. In a few cases, however, I have wit- 
nessed both paralysis of the bladder and of the sphincter 
coming on late in the course of the disease, and evidently 
dependent on it. 

Electro-muscular irritability is rarely impaired. Reflex 



432 DISEASES OF THE SPINAL CORD. 

excitability is also generally unaffected. In the worst cases, 
tickling the sole of the foot will cause the leg to be drawn 
up, even against the volition of the patient. 

Disorders of sensibility are not prominent features in 
anaemia of the antero-lateral columns of the spinal cord. 
Locally there is very rarely pain, and in the paralyzed parts 
there is neither anaesthesia, hyperesthesia, nor abnormal sen- 
sations of any kind. There is never, in the uncomplicated 
affection, the sensation of constriction about any part of the 
body. The stomach and bowels are not often affected, un- 
less there is at the same time some degree of anaemia of the 
posterior columns. But in one very interesting case, occur- 
ring in a lady of this city, and produced by exposure to ex- 
treme cold while crossing to Governor's Island in an open 
boat, there were vomiting every time food was taken into 
the stomach, and the most obstinate constipation I have 
ever witnessed. It very frequently happened that this lady 
had no operation from her bowels for over a month. 

Causes. — Anaemia of the antero-lateral columns of the 
spinal cord may be produced by any cause capable of inter- 
rupting the flow of blood to the region in question, of less- 
ening the calibre of its autocthonous arteries, or of so lower- 
ing the quality of the blood as to unfit it for the purposes 
of nutrition. 

Thus it may be caused — though not without the impli- 
cation of the posterior columns — by abdominal tumors com- 
pressing the aorta, or by disease of this vessel, leading to 
partial or complete obliteration ; by thrombosis or embolism 
of the spinal arteries ; or by direct loss of blood from vessels 
supplying the cord, or deriving their blood from the spinal 
vessels. 

The calibre of the intra- spinal vessels may be lessened 
through the influence of extreme cold, and anaemia of the 
antero-lateral columns thus induced. Several cases of this 
kind have come under my care, in which paraplegia has 
supervened suddenly during or after exposure to very low 



SPINAL ANAEMIA, ETC. 433 

temperature, especially when combined with a moist state 
of the atmosphere. Lying on damp ground has caused it in 
a number of instances. 

It not unfrequ entry follows exhausting diseases of various 
kinds. I have known it to supervene on dysentery, diar- 
rhoea, cholera, typhoid fever, typhus, diphtheria, and several 
other affections. 

But the most common cause of the disorder is undoubt- 
edly peripheral irritation, and this is very frequently an 
affection of the genito-urinary organs. My friend Dr. S. 
Weir Mitchell 1 has written very exhaustively on this sub- 
ject, and has shown the relation which exists between the 
different paralyses now usually called reflex, and injuries of 
nerves. Under the head of pathology I shall have occasion 
to return to Dr. Mitchell's valuable contributions. 

Diagnosis. — Anaemia of the antero-lateral columns of the 
cord is distinguished from congestion by the facts that the 
symptoms are mitigated by the recumbent position instead 
of being increased in violence, as in the latter affection ; 
that the paralysis shows no tendency to become more severe, 
and that, when the bladder or rectum is involved, the diffi- 
culty precedes the paralysis. 

From anaemia of the posterior columns, it is diagnosti- 
cated by the fact that the more obvious symptoms are related 
to motility, sensibility not being involved, while in the for- 
mer the reverse is the case. 

The diagnosis from myelitis will be pointed out when 
inflammation of the cord is under consideration. 

Prognosis. — The probability of a favorable termination is 
great. In fact, no affection of the cord is so susceptible of 
cure when there is no mechanical obstruction in the aorta 
or spinal arteries. But this opinion is expressed with the 

1 Circular No. 6, 1864, Surgeon-General's Office. Reflex Paralysis, by Drs. 
Mitchell, Morehouse, and Keen. Also Wounds and Injuries of Nerves by the 
same, Philadelphia, 1864. Also Paralysis from Peripheral Irritation, by Dr. 
Mitchell, New York Medical Journal, February, 1 866. 
28 



434 DISEASES OF THE SPINAL CORD. 

understanding that the cause must first be removed. So 
long as this continues in action, anaemia of the antero-lateral 
columns of the cord is a very obstinate affection. When 
the arteries are obstructed, then, as in the brain under like 
conditions, softening of the cord may take place. 

Morbid Anatomy and Pathology. — Post-mortem examina- 
tion, of persons who have suffered with symptoms indicative 
of what I consider" to be anaemia of the antero-lateral col- 
umns of the cord, does not reveal the existence of any ma- 
terial spinal lesion. The reason for this is that anaemia of 
the cord is, in the nature of things, a very difficult disease to 
detect, and cannot be definitely made out, unless the capil- 
laries are measured under the microscope. 

But it is this very absence of obvious lesions which indi- 
cates very positively the existence of anaemia, and the char- 
acter of the symptoms shows that the antero-lateral columns 
are its seat. 

Several varieties of paralysis result from anaemia of the 
antero-lateral columns. Classing these as Mitchell 1 has 
done, from their apparent causes, we find that there are — 

1. Paralyses arising during disease of the genito-urinary 
organs. 

2. Those which occur during or just after dysenteries, 
diarrhoeas, super-purgation, or in connection with worms. 

3. Such as arise during or after pneumonia or pleurisy. 

4. Such as are seemingly brought on by dentition. 

5. The paralysis of diphtheria, fevers, and eruptive dis- 
orders. 

6. Such as seems to be occasioned by cold, or by cold 
and moisture. 

7. Paralysis due to external injury. 
To this list may be added — 

8. Paralysis resulting from certain medicines and drugs. 

9. Paralysis due to great emotional disturbance. 

1 Paralysis from Peripheral Irritation, with Reports of Cases, New York 
Medical Journal, February, 1866, p. 323. 



SPINAL ANAEMIA, ETC. 435 

Many cases of each of these varieties of paralysis have 
come under my notice, and there are few medical practi- 
tioners who have not witnessed instances referable to one 
or more of the foregoing categories. The principal theories 
of their immediate canse are — 

1. That of Mr. Stanley, 1 by which certain varieties of 
paralysis are attributed to the transmissal of an irritation 
from a diseased organ to the spinal cord, whence it is re- 
flected to the muscles as paralysis. 

This is no explanation at all, and leaves the condition of 
the cord out of consideration. There is no proof whatever 
that an irritation can, without causing change in the struct- 
ure of a nervous centre, induce either paralysis of motion 
or of sensation. 

2. That of Dr. Brown-Sequard, 2 which ascribes the affec- 
tions in question to a lesion of the cord, consisting in a 
spasm of the spinal vessels by which their calibre is dimin- 
ished. This spasm is, according to this eminent neurologist, 
the result of a peripheral irritation transmitted through the 
nerves coming from a diseased organ or part of the body, to 
the vaso-motor nerves of the portion of the cord giving ori- 
gin to these nerves. 

This was, so far as I have been able to ascertain, the first 
attempt to designate the character of the lesion, which, as 
will be at once perceived, is anaemia. That anaemia can be 
induced by peripheral irritation is, I think, well established. 
But though this theory accounts for many cases of spinal 
paralysis, such as are now under notice, it will not embrace 
all, for we may have anaemia and consequent loss of motor 
power resulting from other causes than irritation. More- 
over, Dr. Brown-Sequard did not fix the lesion in the 
antero-lateral columns, nor associate the symptoms with 

1 On Irritation of the Spinal Cord and its Nerves in Connection with Disease 
of the Kidneys, Medico-Chirurgical Transactions, vol. xviii., p. 260. 

2 Lectures on the Diagnosis and Treatment of the Principal Forms of Paral- 
ysis of the Lower Extremities, Philadelphia, 1861. 



436 DISEASES OF THE SPINAL CORD. 

any derangement in the structure of this region of the 
cord. 

3. Dr. Mitchell, in the paper to which I have already 
referred, divides the several kinds of paralysis mentioned 
into three classes : those which are asserted to be due to dis- 
ease of the genito-urinary system, a cause which he denies 
in toto / those which are said to be produced by peripheral 
irritation of the intestinal canal, an influence which he also 
in great part denies ; and those which follow wounds and 
injuries of nerves. 

Dr. Mitchell rejects altogether the reflex theory of Dr. 
Brown-Sequard, and says : 

" If I were now to sum up the probabilities in the way 
of causation of palsies peripherally induced, I should be dis- 
posed to refer some cases to exhaustion from too constant or 
excessive exercise of normal functions, and others to irrita- 
tion from disease or injury, and to consequent exhaustion 
of the centres ; while, as regards the intervention of vascular 
agency, I should reject the idea of prolonged vasal spasm, 
and consider it possible that in some instances over-excita- 
tion might result in dilatation of the vessels, in which case 
some material lesion would surely result if the condition in 
question were of long continuance." 

While not prepared to accept Dr. Mitchell's views in their 
entirety, they are, in my opinion, perfectly in accordance 
with the doctrine of anaemia of the antero-lateral columns. 
As to whether this anaemia is the result of spasm of the spi- 
nal vessels, or exhaustion, is a question which, for the pres- 
ent at least, is not definitely settled. My own opinion is 
that paralyses of apparently peripheral origin are referable 
to anaemia, produced in some cases by vaso-motor spasm, 
and in others by nervous exhaustion. 

The experiments of Kiissmaul and Tenner * are perfectly 
conclusive as to the effects of cutting off the supply of blood 

1 The Nature and Origin of Epileptiform Convulsions caused by Profuse 
Bleeding, etc. New Sydenham Society Translations, London, 1859, p. 53, el seq. 



SPINAL ANEMIA, ETC. 437 

to the spinal cord. These observers compressed the aorta 
in rabbits so completely that not a drop of blood could reach 
the spinal cord below the point of occlusion. The conse- 
quence was that there was complete paralysis of all the mus- 
cles receiving their nervous influence from the anaemic por- 
tion of the cord. The possibility, therefore, of spinal anae- 
mia producing paralysis, is beyond doubt. In these experi- 
ments, however, the blood was of course shut off from both 
the anterior and posterior columns, and therefore the phe- 
nomena were not those of simple motor paralysis. 

In practice, likewise, we often find that the anaemia 
is not restricted to either set of columns, and that the 
symptoms are accordingly those of motor paralysis, aber- 
rations of sensibility, and functional disturbances in various 
organs, such as we have just considered as being caused by 
anaemia of the posterior columns. 

Treatment. — The treatment is similar in general features 
to that applicable to anaemia of the posterior columns al- 
ready considered, though there is not the same benefit to be 
derived from counter-irritation. The indications, therefore, 
are to remove the cause, to improve the general tone of the 
system, and to increase the amount of blood in the spinal 
vessels. 

So far as the first indication is concerned, it very often 
happens that its fulfilment is sufficient for the entire re- 
moval of the anaemia, and the disappearance of the conse- 
quent paralysis. This is especially the case as regards those 
instances which are due to peripheral irritations of various 
kinds. Within the last few days a young lady, aged twelve, 
was brought to me by her mother to be treated for para- 
plegia, which had developed very suddenly. There was no 
evidence of serious organic difficulty, and no apparent cause 
of peripheral irritation. Her symptoms, however, all point- 
ed to anaemia of the antero-lateral columns, and, on the 
principle of exclusion, I thought it probable there might be 
worms in the alimentary canal. I therefore administered 



438 DISEASES OF THE SPINAL CORD. 

several doses of santonine, followed by castor-oil. A num- 
ber of lumbrici were discharged, and the paralysis disap- 
peared in the night as suddenly as it had arisen. 

In another case, a gentleman was rendered paraplegic 
soon after contracting a catarrhal inflammation of the blad- 
der. The bladder affection was disregarded by his physi- 
cian, and energetic means were used against the paralysis, 
but without effect. I suggested the expediency of suspend- 
ing the administration of the strychnia and the application 
of counter-irritants to the spine, and directing attention to 
the cure of the bladder difficulty. This was done, and, at 
the same rate as the inflammation yielded to the treatment, 
the paraplegia disappeared. 

The general tone of the system is to be improved by 
such measures as were recommended for the accomplishment 
of the same end in anaemia of the posterior columns. 

For fulfilling the third indication, strychnia and phos- 
phorus are preferable to any internal remedies. I usually 
prescribe them together in doses of the tenth of a grain of 
the phosphide of zinc, with from a third to a half a grain of 
the extract of nux- vomica in pill, to be taken three times a 
day. Lately, however, I have pursued the practice of giv- 
ing the strychnia in gradually-increasing doses till there is 
evidence of its characteristic physiological effects being pro- 
duced. Two grains of the sulphate of strychnia are to be 
dissolved in an ounce of water, and ten minims, containing 
one twenty-fourth of a grain of strychnia, given three times 
a day ; the next day eleven minims are administered for 
each dose, the next twelve, and so on till, as often happens, 
the paralysis yields, or till the reflex excitability of the legs 
is increased, or stiffness of their muscles or those of the 
nucha is induced. In either of these latter events the ad- 
ministration must be stopped for a day, and then the original 
dose of ten minims be given and increased as before. There 
is, according to my experience, no medication so effectual in 
all those forms of paralysis called reflex, inhibitory, func- 



SPINAL ANiEMIA, ETC. 439 

tional, etc., and which, in my opinion, result from anaemia 
of the antero-lateral columns of the cord, as this with 
strychnia. It requires care and prudence, and, if these 
qualities be exercised, is perfectly safe. It very generally 
happens that, before the patient reaches thirty minims (one- 
eighth of a grain) for a dose, the paralysis begins to yield. 
In one case, however, due to exposure to severe cold, I was 
obliged to carry the dose to sixty minims — equal to one- 
fourth of a grain of strychnia — before the excitability of the 
cord was increased, or any signs of the paralysis yielding 
were observed. The patient recovered after taking three- 
quarters of a grain of strychnia daily for over two weeks. 

My notes show that in the last year I have treated, ac- 
cording to the method described, sixty -one cases of paralysis 
due to anaemia of the antero-lateral columns, and that all 
were cured. It is true, galvanism was used in some of 
them, and phosphorus in others, but the successful results 
were evidently mainly due to the strychnia. 

The only local application which is decidedly beneficial 
is the constant galvanic current, which should be used in 
the manner recommended for anaemia of the posterior col- 
umns. 

As regards the paralyzed muscles, the induced or fara- 
daic current is useful in keeping them exercised, and thus 
preserving their nutrition. Friction and kneading exercise 
a like effect. 

In those cases of spinal anaemia due to obstruction of the 
aorta, or occlusion of spinal vessels by emboli, no specific 
treatment is of any avail. 



CHAPTEE III. 

SPINAL HEMORRHAGE— SPINAL MENINGEAL 
HAEMORRHAGE. 

These two conditions having a common cause, being 
often associated and having a general resemblance to each 
other, may properly be considered together. 

Symptoms. — A haemorrhage into the substance of the 
spinal cord is characterized by pain at the seat of the lesion, 
and by derangements of sensibility and of the power of mo- 
tion in all those parts of the body below. These consist or- 
dinarily of anaesthesia and loss of motility, but occasionally 
there are hyperesthesia and spasms. In the great majority 
of cases the bladder and its sphincter and the sphincter ani 
are also paralyzed. Reflex excitability and electro-muscular 
contractility are soon impaired or altogether lost. 

If the seat of the haemorrhage be high up in the neck, 
death is almost instantaneous from the paralysis of the phre- 
nic nerve. 

When the lesion is meningeal, the symptoms are not gen- 
erally so rapidly developed as when it is situated in the sub- 
stance of the cord. The pain is greater and there is a more 
decided tendency to spasmodic jerkings in the limbs receiv- 
ing their nerves from the part of the cord below the extrava- 
sation. Hyperesthesia may alternate with anaesthesia, or 
this latter may alone be present. 

The extent of motor paralysis is very variable, both as 
regards intensity and diffusion. Sometimes all the muscles 
below the seat of the lesion are more or less paralyzed ; at 



SPINAL HEMORRHAGE, ETC. 441 

others, some muscles altogether escape. I have a patient at 
the present time under treatment who has, in consequence 
of a spinal haemorrhage, probably meningeal, lost sensation 
in a small region of skin over the glutei muscles, and sensa- 
tion and motion in all the tissues below both knees. Sensa- 
tion and motion are intact in all other parts of the lower 
extremities. The bladder is unaffected, but there is very- 
obstinate constipation. 

Beflex excitability is often exaggerated, and the electro- 
muscular contractility increased in the early stage ; but, if 
the patient survives the immediate effects of the lesion, both 
these faculties become impaired. Meningeal haemorrhage 
taking place above the third cervical vertebra may be 
speedily fatal, from the interruption to respiration due to 
paralysis of the phrenic nerve. 

Causes. — Spinal haemorrhage, either in the substance of 
the cord or of the membranes, is almost invariably the result 
of injury. Thus it may be caused by blows on the verte- 
bral column, by falls, or by gunshot, Or by wounds with pen- 
etrating instruments. It may also be produced by tetanus 
and by the rupture of aneurisms, but is in either of these 
cases meningeal. 

Diagnosis. — The diagnosis must mainly be determined by 
the history of the case, and by the facts that the symptoms 
come on suddenly and advance rapidly. 

Prognosis. — Death is the almost invariable result. I have, 
however, known two instances of recovery. In one of these 
the patient, a boy of about fifteen, was thrown from his 
horse. Paralysis supervened immediately, and there was a 
severe pain at about the eleventh dorsal vertebra. The 
bladder was also paralyzed. For several weeks his life was 
despaired of, but he eventually recovered with the para- 
plegia remaining, and the necessity of drawing off the urine 
with a catheter. I saw him five years after the injury. He 
was still paraplegic, and the bladder was still paralyzed. 
Careful examination failed to show any displacement or 



442 DISEASES OF THE SPINAL COED. 

fracture of the vertebra, and I therefore felt warranted in 
concluding that there had been a spinal haemorrhage, prob- 
ably meningeal. The other case has been already cited. In 
this, the patient fell through a hatchway a distance of thirty 
feet, and struck on his back. Paralysis was almost immedi- 
ate. He came under my care fifteen years after the event, 
and I diagnosticated a meningeal spinal haemorrhage from 
the facts that there had been violent jerkings of the limbs 
and intense lumbar pain. There were no signs of fracture 
or displacement. 

Morbid Anatomy and Pathology. — The extravasation in 
haemorrhage into the substance of the cord is generally 
seated in the gray matter, and shows a greater tendency to 
extend longitudinally than laterally. The white matter is, 
however, occasionally involved. 

The changes which ensue in the clot and in the limiting 
tissue are similar to those which take place in cerebral haem- 
orrhage. 

In spinal meningeal haemorrhage the blood is extrava- 
sated either between the bones and the dura mater, between 
the dura mater and the arachnoid, or between the arachnoid 
and the pia mater. The clot may be very small or very 
large. The latter is more frequently the case. 

The symptoms which follow spinal haemorrhage are the 
results of excitation and compression — the hyperesthesia 
and the spasms being due to the former, and the anaesthesia 
and motor paralysis to the latter. 

Treatment. — There is nothing to do in cases of spinal 
haemorrhage but to maintain the patient in as quiet a con- 
dition as possible, and to keep ice constantly applied to the 
vertebral column. If there is time, ergot might, I think, be 
administered with advantage. In two cases which I have 
had the opportunity of observing from the first, both caused 
by falls from the loft of a stable, death took place within 
six hours ; the symptoms gradually becoming more profound 
and advancing upward. After death, the haemorrhage was 



SPINAL HEMORRHAGE, ETC. 443 

found to occupy the whole length of the spinal canal, and 
was seated between the bones and the dura mater. Of 
course, in cases like these, no therapeutical means can avail, 
and, even in slighter cases, treatment is of little if any ser- 
vice. 

We may, however, by perfect rest, ice to the spine, 
leeches to the anus, and the administration of ergot, some- 
times prevent haemorrhage in cases of injuries of the cord 
which otherwise might be followed by extravasation. 



CHAPTER IY. 

SPINAL MENINGITIS. 

Inflammation of the membranes of the spinal cord may 
be either acute or chronic. 

ACUTE SPINAL MENINGITIS. 

Acute inflammation may be seated either in the dura 
mater, the arachnoid, or the pia mater of the cord, or may 
simultaneously attack all three membranes. 

Symptoms. — The symptoms indicating inflammation of 
the dura mater are not very decided, and beyond the occur- 
rence of pain may not be observed at all. When combined 
with inflammation of the arachnoid and pia mater, the phe- 
nomena are more pronounced. 

Acute inflammation of the arachnoid does not of itself 
give rise to characteristic symptoms, and it is rarely the 
case that it exists separately. 

Acute inflammation of the pia mater can, however, be 
recognized without difficulty. It begins with a chill, as do 
others of the phlegmasia, and this is soon followed by fe- 
brile excitement. At the same time there is intense pain in 
the back, which is aggravated by every movement of the 
patient, but not by pressure on the part of the spine 
over the diseased portion of the membrane. Those nerves 
which have their origins from the affected region are the 
seat of severe pain, which is transmitted through their 
trunks and branches to distant parts of the body. Spasms 
of the muscles of the back are commonly present. These 



SPINAL MENINGITIS. 445 

are tonic in character, and may be so severe as to bend the 
body backward, producing an appearance like the opisthot- 
onos of tetanus. At the same time the limbs below the 
seat of the lesion are strongly contracted. I have witnessed 
cases in which the knees were drawn up to the chin, and 
the heels to the buttocks. 

At the same time there is impairment of motor power in 
all those parts of the body supplied by nerves coming from 
the cord below the diseased region, and in some cases volun- 
tary control over the muscles is entirely lost. 

So long as the affection is confined to the membranes of 
the lower portion of the cord, a fatal result may be deferred 
for some time, and the disease may become chronic ; but, 
if it extends upward so as to involve the region from which 
the phrenic nerves arise, death very soon takes place by 
asphyxia. 

So long as the spinal cord remains free from the disease, 
the reflex excitability and electro-muscular contractility re- 
main unimpaired. 

The bladder is not often involved, and the bowels may 
be obstinately constipated, or the fecal matters may be 
passed involuntarily. 

CHRONIC SPINAL MENINGITIS. 

This may arise in consequence of an acute attack, or it 
may be developed spontaneously. As in the acute form of 
the affection, pain constitutes a prominent feature, and is 
situated both in the spinal region and in other parts of the 
body. Spasms and contractions of the lower extremities, 
and spasms of the muscles of the back, are likewise promi- 
nent symptoms. 

The pain in the spine is not increased by steady pressure 
over the vertebrae, but it is greatly aggravated by every 
movement of the body ; for by such motion the nerves are 
compressed as they leave the spinal canal, and, as they are 
already in a condition of erethism, pressure cannot be borne. 



446 DISEASES OF THE SPINAL CORD. 

The abnormalities of sensation are usually in the way of 
hyperesthesia, which may sometimes be very acute. 

The paralysis advances gradually, and rarely, at first, 
is very intense in any group of muscles. It is likewise sub- 
ject to great variations in the degree of severity. Some- 
times the patient finds that he walks tolerably well one day, 
while the next he can scarcely move a limb. These differ- 
ences depend on the amount of fluid effused, which is sub- 
ject to changes from day to day. 

The bladder is sometimes paralyzed, the sphincter may 
be similarly affected, or this latter may be subject to repeat- 
ed attacks of spasm, by which the evacuation of the urine 
is prevented. 

The bowels, as in the acute form of the disease, may be 
either constipated, or the sphincter ani may be so paralyzed 
as to allow of the involuntary passage of the fecal matters. 

Reflex excitability is rarely lessened, and is often consid- 
erably increased. In the case of a gentleman from Ohio 
who was recently under my charge for chronic spinal me- 
ningitis, the slightest touch on the sole of the foot was suffi- 
cient to cause the limb to be violently drawn up ; and, in 
the case of a lady from New Orleans similarly affected, the 
Contact of the bedclothes produced a like effect. 

In several cases I have observed that any mental agita- 
tion, or even the attention directed to the affected limbs, 
was sufficient to cause violent spasmodic contractions. 

Electro-muscular contractility is not generally impaired. 

The symptoms are usually aggravated by the recumbent 
posture. 

Bed-sores are a frequent accompaniment of chronic spi- 
nal meningitis. 

Causes. — The most common cause of spinal meningitis, 
either acute or chronic, is exposure to cold and moisture. 
Several cases have come under my charge which clearly 
resulted from lying on the cold and damp earth, and from 
going to sleep in this situation. In one case which occurred 



SPINAL MENINGITIS. 447 

in a railway conductor, the train of which he had charge 
was obstructed in its passage by a heavy drift of snow. 
While workmen were cutting a way through it, he lay down 
on a pile of snow, and, being greatly exhausted, soon fell 
asleep. Soon after being awakened he had a slight chill 
and a mild fever, and the following day experienced severe 
pain in the back. This was soon followed by the other 
symptoms of spinal meningitis, not very intense in charac- 
ter, but persistent, for the affection passed into the chronic 
form. Two cases have come under my notice in which the 
affection was caused by the back being exposed to a strong 
and cold wind. 

On account of this influence of cold in producing spinal 
meningitis, the disease is far more common in winter than 
in summer. Of thirty-nine cases that I have treated wholly 
or in part during the last six years, twenty-three occurred 
in the months from November to March inclusive. 

Exposure to the direct rays of the sun is said to induce 
spinal meningitis, but I have never witnessed a case in 
which this cause could reasonably be inferred. I may make 
the same remarks in regard to the effects of strong muscular 
exercise. 

It is, however, sometimes a consequence of wounds and 
injuries. Seven of the cases under my charge were due to 
traumatic causes. 

Rheumatism is likewise an occasional cause. 

Diagnosis. — The diagnostic phenomena of spinal menin- 
gitis, either of the acute or chronic form, are the pain in the 
back, increased on any movement of the spinal column ; the 
pains in the course of the nerves having their origin from 
the diseased region ; the tonic spasms of the muscles of the 
back, and of other parts of the body ; the exaltation of reflex 
excitability ; and the variations which take place in the ex- 
tent and intensity of the paralysis. 

Prognosis. — The course of spinal meningitis is generally 
progressively onward to a fatal termination — the patient 



448 DISEASES OF THE SPINAL CORD. 

dying either by the gradual extension of the disease upward 
so as to involve more important nerves in the lesion, by the 
development of some intercurrent affection, or by exhaustion. 
I have, however, seen three cases in which the disease was 
arrested, and which will be more specifically referred to 
under the head of treatment. And Ollivier, 1 Brown-Se- 
quard, 2 and Jaccoud, 3 admit the possibility of cure. 

Morbid Anatomy and Pathology. — The lesions found after 
death from spinal meningitis may be confined to any one of 
the membranes, but more generally are restricted to the pia 
mater and the sub-arachnoid space. They consist in thick- 
ening of the membrane, spots of opacity, turgidity of the 
vessels, and the effusion of a large quantity of spinal fluid. 
This fluid is occasionally clear, but is more frequently full 
of flocculent matter, or is tinged with blood. 

The alterations found in the arachnoid are of similar 
character, with the addition that there are numerous hard 
cartilaginous plates scattered through the diseased part of 
the membrane, which vary in size from that of a grain of 
wheat to a mustard-seed. 

The dura mater, when it has been the seat of inflamma- 
tion, becomes thickened and adherent to the bone. Occa- 
sionally it is perforated by the supervention of gangrene, and 
the pus collected between it and the vertebrae escapes into 
the space between the dura mater and arachnoid, and excites 
general meningitis. The theory of the symptoms observed 
in spinal meningitis is, that they are due to two immediate 
causes, excitation and pressure. The former is the result 
of the hyperemia, the latter of the increased amount of spi- 
nal fluid causing pressure. 

Treatment. — In the acute form of spinal meningitis, active 
measures are required. The application of leeches to the 
painful part of the spine, or of cups, so as to effect local de- 
pletion, will generally prove useful. Hydragogue cathartics 

1 Traite des Maladies de la Moelle ^piniere, etc., Paris, 1827, t. ii., p. 295. 
8 Op. cit., p. 82. 3 Op. cit., p. 302. 



SPINAL MENINGITIS. 449 

are also beneficial, for by their action the vessels of the in- 
flamed membranes are depleted of their blood, and the ex- 
cessive amount of spinal fluid effused is in consequence 
more readily absorbed. 

Mercury may also be advantageously administered either 
by inunctions with mercurial ointment or by calomel given 
internally, or by both these means. Calomel should be given 
in doses of from one to two grains every three or four hours, 
till the system is brought under its influence, as manifested 
by fetor of the breath. 

The patient should be kept as quiet as possible, and should 
be enjoined not to lie on the back. For the relief of the 
dorsal and other pains, suppositories, containing each,half a 
grain of codeine, are often efficacious. They may be admin- 
istered night and morning. 

In the chronic form of the disease, depletion by blood- 
letting in any form is not so beneficial as in the acute variety 
or as in spinal congestion. Blisters are more admissible, 
and scarcely ever fail to do good. They should be applied 
on each side of the spinal column near the diseased region 
of the cord, and as soon as one heals another should take its 
place. The actual cautery I have never used, nor have I 
ever seen such good results from its employment as from the 
action of blisters. Purgatives are also useful for the same 
reasons which prevail in acute spinal meningitis. 

Iodide of potassium is always a valuable agent, indeed 
more so than any other remedy employed in chronic spinal 
meningitis. I employ it in the form of a saturated solution, 
which contains about a grain to each drop. Of this, I ad- 
minister the first day seven drops three times, preferably 
before meals ; the next day eight drops to the dose, the next 
nine, and so on, till the patient takes from forty to sixty 
drops at the dose, according to circumstances. The iodide 
of potassium always acts best when largely diluted with 
water, so that, as the doses are increased, an additional 
quantity of water should be used. 
29 



450 DISEASES OF THE SPINAL CORD. 

I very often employ the corrosive chloride of mercury in 
combination with the iodide of potassium, in doses of the 
sixteenth of a grain with each dose of the iodide. 

Diuretics may also frequently be given with advautage. 
Their object is the same as that which governs in the admin- 
istration of purgatives. 

In two of the cases cured, to which reference has been 
made, I derived the greatest benefit from repeated blisters, 
and the persistent use of iodide of potassium. The latter 
was carried to the extent of fifty grains three times a day 
in one of these cases, and sixty-five in the other. 

At the same time the primary galvanic current was ap- 
plied to the spine in the manner recommended for spinal 
congestion, and the induced current to the paralyzed limbs. 
I am very sure that electricity in both these forms should be 
used in most cases of chronic spinal meningitis. The fol- 
lowing case, reported by J. Frank, 1 and quoted by Ollivier, 2 
of acute spinal meningitis, is instructive : 

" A captain, aged forty-two years, of sanguineo-bilious 
temperament, subject to rheumatic pains and haemorrhoids, 
and addicted to the use of alcoholic liquors, was suddenly 
seized on the evening of the 2d of March, 1819, with a chill, 
which was soon succeeded by a burning fever, accompanied 
by pain in the lumbar region. During the night the pain 
increased, extended as high up as the occipital region, and 
gradually acquired great intensity. J. Frank was called in 
the morning at Hive o'clock, to see the patient, who was suf- 
fering acutely. He was uttering loud groans, was lying on 
his belly, with the superior and inferior extremities stretched 
out to their full length. To the questions put to him, the 
patient answered with great difficulty that he had pains all 
over his body, that he was unable to open his eyes, that his 
teeth were strongly clinched, and that a burning and pulsat- 
ing pain extended from the occiput to the lower extremity 

1 Praxeos Med., etc., de rachialgite, tome vi., p. 76. Turin, 1822. 

2 Op. eit., p. 295. 



SPINAL MENINGITIS. 451 

of the vertebral column. The limbs, especially the inferior, 
were without sensation, but were agitated by occasional 
jerkings. There was such a constriction of the chest that 
breathing was scarcely possible, and the abdomen was like- 
wise in a state of contraction. There were constipation, 
incontinence of urine, a pulse soft but 100 per minute, occa- 
sional palpitations of the heart, and a hot aud dry skin. 

" Frank at once opened a vein in the foot, and abstract- 
ed sixteen ounces of blood. A dozen leeches were applied 
around the occiput, and as many scarified cups on each side 
of the spine. A decoction of tamarinds was given as a 
cathartic. These means were sufficient to restore the health 
of the patient in a few days. The bloodletting produced 
an almost immediate cessation of all the symptoms ; for, a 
short time after its employment, the movement of the eye- 
lids became easy, as well as that of the jaw ; sensation re- 
appeared in the extremities, and the dorsal pain diminished 
considerably in intensity." 

As Ollivier remarks in regard to this case, several of the 
symptoms are those of spinal congestion. The sudden su- 
pervention of the disease, as well as its rapid disappearance, 
points to that affection. Nevertheless, its general features 
are those of acute spinal meningitis — an affection which, of 
course, cannot exist without congestion. 

In a very interesting case under my charge several 
months ago, a cure of the spinal difficulty, which was 
chronic spinal meningitis probably of syphilitic origin, 
was accomplished by the use of the iodide of potassium 
and the corrosive chloride of mercury, as recommended 
on pages 449 and 450. In this case the affection had 
lasted for several years, and extended from the occiput 
to the lower extremity of the spinal cord. The limbs 
were constantly subject to violent spasmodic jerkings, 
and both legs and one arm were in a permanent state of 
contraction, which had existed for three years. Under 
the use of the iodide and the mercury, as mentioned, the 



452 DISEASES OF THE SPINAL CORD. 

pain, which had been intense, ceased, the spasms of the 
limbs were stopped, the bladder regained its expulsive 
power, the bowels again began to act without purgatives or 
injections being required, and the limbs could be moved as 
extensively as the rigid contractions permitted. These had 
existed so long that the flexor muscles had become much 
shortened, and the skin in the groins and popliteal spaces 
was tense and unyielding. The accompanying woodcut 
(Fig. 21) shows the positions of the legs and arm at this 
time. Under these circumstances I requested the advice of 
my friend Prof. L. A. Sayre, and after consultation it was 
determined to divide the tendons of the tensor vaginae femo- 
ris, the sartorius, the gracilis, and the biceps, on each side. 
When this was done by Prof. Sayre, the patient being under 
chloroform, careful but powerful efforts at extension were 
made, and the skin in the popliteal space on both sides was 
necessarily torn, owing to its contraction and inelasticity; 
the limbs were thus brought into a state of complete exten- 
sion, and, by a system of weights and pulleys similar to that 
used in Buck's fracture apparatus, they were kept in this 
position. The patient was, however, too weak to endure 
the fatigue of the necessary extension and confinement. He 
took off the weights whenever they caused pain or great 
uneasiness. To add to the difficulties, a large bed-sore 
formed on the right buttock, and the strength of the pa- 
tient declined so rapidly that, in order to save his life, the 
apparatus had to be entirely removed. He rapidly recov- 
ered, but, as cicatrization went on, the limbs again became 
contracted, and in the course of two or three months were 
as bad as ever. Pain in the back soon afterward super- 
vened, the legs and one arm began to be affected with 
spasms, and the paralysis also returned. A renewal of the 
former medication again caused relief, and the patient has 
to this day remained free from any spinal difficulty, though 
his legs are still contracted. This is the third case of cure 
referred to as happening in my experience. 



SPINAL MENINGITIS. 
Fig. 21. 



453 




454 DISEASES OF THE SPINAL CORD. 

For the cure of the bed-sores the method recommended 
by Dr. Brown-Sequard may be used. It consists in the 
alternate application of sponges, one of which is saturated 
with hot water and the other with cold water. This should 
be done for five or ten minutes every day, and the effect is 
to increase the activity of the circulation of the part, and 
to promote the formation of granulations. 

But I have generally preferred the method by galvanism 
first suggested and employed by Crussel, 1 of St. Petersburg, 
and which I used for the treatment of indolent ulcers with 
almost invariable success, in 1859, when surgeon to the Bal- 
timore Infirmary. The method was also recommended by 
Mr. Spencer Wells. 2 During the last six years I have em- 
ployed it to a great extent in the treatment of bed-sores 
caused by diseases of the spinal cord, and with scarcely a 
failure — indeed, I may say without any failure except in 
two cases where deep sinuses had formed which could not 
be reached by the apparatus. 

A thin silver plate, no thicker than a sheet of paper, is 
cut to the exact size and shape of the bed-sore. A zinc 
plate of about the same size is connected with the silver 
plate by a fine silver or copper wire six or eight inches in 
length. The silver plate is then placed in immediate con- 
tact with the bed-sore, and the zinc plate on some part of 
the skin above — a piece of chamois-skin, soaked in vinegar, 
intervening. This must be kept moist, or there is little or 
no action of the battery. Within a few hours the effect is 
perceptible, and in a day or two the cure is complete in the 
great majority of cases. In a few instances a longer time is 
required. I have frequently seen bed-sores three or four 
inches in diameter, and half an inch deep, heal entirely over 
in forty-eight hours. Mr. Spencer Wells states that he has 

1 Neue Med.-Chirurg. Zeitung, No. 1, 1847, p. 235. 

2 Lectures on Electricity and Galvanism, by Dr. Golding Bird, London, 1849, 
appendix. There is an American edition of this very interesting little book, 
but it has long been out of print. 



SPINAL MENINGITIS. 455 

often witnessed large ulcers covered with granulations with- 
in twenty-four hours, and completely filled up and cicatriza- 
tion begun in forty-eight hours. During his recent visit to 
this country I informed him of my experience, and he re- 
iterated his opinion that it was the best of all methods for 
treating ulcers of indolent character and bed-sores. 

Ergot is not so generally useful as in congestion, though 
I rarely fail to give it at some time or other in cases of 
chronic meningitis, with a view to the relief of the ac- 
companying congestion. Strychnia is not at all admissible 
at any time. Reeves 1 recommends it in those cases in 
which pains, cramps, and contractions, are absent, but I 
have never seen such cases. Indeed, a case in which they 
were not prominent symptoms could scarcely be regarded as 
one of spinal meningitis. 

1 Diseases of the Spinal Cord and its Membranes, and the Various Forms of 
Paralysis arising therefrom. London, 1858, p. 55. 



CHAPTEE V. 

ACUTE MYELITIS. 

Acute inflammation of the substance of the spinal cord 
is not a very common affection, but it is so essentially dis- 
tinct in its symptoms and results from chronic myelitis that 
it requires separate consideration. 

Symptoms. — A chill is generally the first symptom ob- 
served, and this is followed immediately by high febrile 
excitement, during which the pulse often reaches a rapidity 
of 160 per minute. Alterations of sensibility and motility 
are noticed with the inception of the fever. 

Among the first, pain in the back, at the seat of the 
lesion, is prominent. It is aggravated by percussion, and 
by the passage of a sponge saturated with hot water, or one 
with cold water, over the affected region. It is not, how- 
ever, so intense in character as that attendant on menin- 
gitis. 

The limbs below the seat of the inflammation are like- 
wise affected with pains, which are mainly confined to the 
trunks of the nerves coming from the affected portion of the 
cord. 

A pain is also experienced, in the great majority of cases, 
at the upper limit of the inflammation, and which extends 
around the body at that height. It is generally accom- 
panied by a feeling of constriction similar to that which 
would be produced by a cord tightly tied around the body. 
It is probably caused by spasm of the abdominal or thoracic 
muscles. 



ACUTE MYELITIS. 457 

None of these pains are increased by movements of the 
limbs or of the vertebral column, in which respects they 
differ from those met with in spinal meningitis. 

In addition there are various derangements of the cuta- 
neous sensibility in those parts of the skin below the seat 
of the disease, and especially in those parts supplied by 
nerves originating from the affected segments of the cord. 
These consist of formication, " pins and needles," a sensa- 
tion as if water were trickling over the skin, as if the limb 
were asleep, and of sensations of cold or heat. Anaesthesia 
is the most common general condition of the skin, and it is 
often accompanied with cutaneous pains, which are the more 
intense the more profound is the anaesthesia. Thus, if we 
have ascertained that the cutaneous sensibility is very much 
impaired at a particular spot, we will frequently find this 
spot the seat of severe and spontaneous pains. In such 
cases, too, a prick with a pin is felt, but the ability to dis- 
tinguish the two pdints of the aesthesiometer is lost, even 
when they are widely separated. Indeed, they may not be 
felt at all unless they are so used as to cause pain. I have 
several times observed patients whose tactile sensibility was 
almost entirely gone, but whose sensibility to pain was so 
great that they could not endure the contact of the bed- 
clothes. The distinction, therefore, between insensibility 
to touch — generally called anaesthesia — and insensibility to 
pain — analgesia — must be clearly made. 

Hyperaesthesia is occasionally present, but probably not 
unless there is meningitis associated with the myelitis. 

Motility is affected at a very early period of the disease, 
and at first consists of simple twitchings of the muscles, and 
paralysis. The latter comes on with great rapidity, and 
may become complete in a few hours. Jaccoud * states that 
he has seen this result produced in thirty-six hours, and 
Ollivier 2 cites several cases to the same effect. The seat of 

1 Op. cit., page 318. 

2 Op. cit., chap, huitieme, Myelite, ou Inflammation de la Moelle epiniere. 



458 DISEASES OF THE SPINAL CORD. 

the paralysis is in those parts of the body below the diseased 
portion of the cord. Thus, if the lower dorsal, or lumbar 
region be affected, the lower extremities, the sphincters of 
the bladder and rectum, and certain of the abdominal mus- 
cles, are involved ; when the difficulty is in the upper dorsal 
or cervical region, the upper extremities, and, if the lesion 
is high enough, the diaphragm and other muscles of respira- 
tion, with those concerned in effecting deglutition, are par- 
alyzed. Ocular troubles may also be present in cervico- 
dorsal myelitis, from irritation of the sympathetic nerve. 
These consist of dilatation of one or both pupils, and of 
exophthalmos. 

It is not often the case that the homonymous muscles 
are equally paralyzed. Thus it is not uncommon to find 
one lower extremity entirely deprived of motility, and the 
other more or less possessed of its normal amount of power. 
The bladder is sometimes paralyzed, and sometimes not, and 
the same is true of the vesical and anal sphincters. Ke- 
flex power is generally exaggerated in the very first stage, 
and greatly diminished or altogether abolished subsequently. 
In a few cases I have seen tickling the sole of the foot fail 
to excite reflex movements in the lower extremity to which 
it belonged, but induce strong movements in the opposite 
leg. A similar fact has been observed as regards sensation ; 
an impression made upon the skin of one foot, for instance, 
not being felt in that foot, but causing pain in the opposite 
foot. 

Electro-muscular contractility is diminished unless, per- 
haps, in the very earliest stage of the affection, and there is 
almost invariably a tendency to rapid atrophy of the para- 
lyzed muscles. Besides the foregoing symptoms, there are 
usually others referable to the viscera, and which differ ac- 
cording to the seat of the lesion. Thus, if the inflammation 
be seated high up in the cord, the actions of the respiratory 
muscles, of those concerned in deglutition, and of the heart, 
are affected. There may also be vomiting, derangement of 



ACUTE MYELITIS. 459 

the liver, of the kidneys, intestines, and generative organs. 
The urine is often, if not invariably, alkaline, and there are 
frequent, and sometimes constant, painful erections. 

The temperature of the paralyzed limbs always falls, and 
there is a strong tendency to the formation of sloughs and 
bed-sores, which frequently cannot be obviated. I have 
seen, in several instances, large sloughs form on each side 
of the vertebral column within twenty-four hours of the in- 
ception of the attack of acute myelitis. 

Acute myelitis ordinarily runs its course in about three 
weeks, either, as is generally the case, terminating in death 
by asphyxia or exhaustion, or passing into the chronic form 
of the disease. It may, however, end fatally in a few days. 
In one case under my charge, occurring in a child ten years 
of age, and the result of pressure from caries and necrosis 
of the vertebrae, death took place in fifty hours. In another, 
due to a blow, a fatal termination was reached in forty-five 
hours. 

Causes. — Acute myelitis is more frequently the result of 
injury than of any other cause. It is likewise a sequence 
of disease of the vertebrae, extending to the dura mater and 
other membranes, and of meningitis. It is also said to be 
produced by exposure to extreme heat or cold, by violent 
muscular efforts, and by venereal excesses. Seven cases 
have come under my observation. Of these, three were the 
result of wounds, two ensued on disease of the vertebrae, and 
two were caused by extension of acute meningitis. 

Diagnosis. — The principal diagnostic marks of acute 
myelitis are the occurrence of the sensation of constriction 
around the body, the alkalinity of the urine, the rapid super- 
vention of the paralysis, the great predisposition to sloughs 
wherever there is the least pressure, the excitation of pain 
in one part of the body by irritation applied to some other 
part, the causation of reflex movements in a similar way, 
and the marked depression of temperature in the paralyzed 
parts. 



460 DISEASES OF THE SPINAL CORD. 

The absence of the characteristic symptoms of congestion 
and of meningitis will suffice likewise to separate it from 
these affections. 

Prognosis. — The termination of acute myelitis is in death 
sooner or later. Even if it passes into the chronic stage, the 
alterations in the structure of the cord are so extensive as 
to be incompatible with the performance of its functions. 
Death was the result in all the cases that I have person- 
ally observed, and this event occurred in all within three 
weeks. 

Morbid Anatomy and Pathology. — The morbid action in 
cases of acute myelitis may be limited to the white substance 
or to the gray substance, or may attack both these tissues. 
It may likewise affect the antero-lateral columns, the poste- 
rior, or extend to both. Undoubtedly, if we had sufficient 
opportunities to witness cases of spontaneous origin not the 
result of traumatic causes, or of the extension of other dis- 
eases, we should be enabled to distinguish by the symptoms 
which part of the cord histologically or topographically is 
affected. For there can be no doubt that, as in anaemia, or 
as we shall see hereafter in the chronic form of myelitis, the 
symptoms must be as characteristic as are the functions of 
the several histological and regional parts of the cord. 

As regards the obvious morbid anatomical features, we 
find that when the lesion is situated in the white substance 
the membranes of the affected portion are congested, thick- 
ened, opaque in patches, and adherent to the cord. The 
cord is softened to a variable depth, and this portion is 
detached with the membranes if these be removed. This 
softened portion is in the early stage rose-colored and stud- 
ded with red points, marking the situation of the enlarged 
blood-vessels. As the disease advances, the color deepens 
to a reddish brown, then begins to get lighter, and, pass- 
ing through several shades of yellow, eventually becomes 
white. 

When the gray substance is involved, the changes in its 



ACUTE MYELITIS. 461 

physical appearance are similar ; and, when both the white 
and the gray are the seat of the morbid process, it is 
impossible to distinguish the two substances from each 
other. 

Microscopical examination shows the existence of con- 
gestion, and, as an essential feature, an increase in the 
amount of connective tissue or neuroglia of the cord. The 
evidences of this hypertrophy are seen in the increase of 
fusiform cells and in the production of multinuclear cells and 
free nuclei. These formations take place at the expense of 
the proper nervous tissue of the cord, the anatomical ele- 
ments of which undergo atrophy and fatty degeneration. 
The nervous tubules are thus often disintegrated and their 
contents disseminated through the extraneous tissue. The 
axis cylinders are entirely surrounded by oil-globules, or 
are altogether broken up and rendered unrecognizable. 

Should suppuration occur, the elements of pus are ob- 
served among those already described, and take their place 
to a considerable extent. 

In case of the passage of acute myelitis into the chronic 
form, the centre of inflammation usually undergoes other 
changes, which, however, still maintain the general charac- 
teristic of hypertrophy of the neuroglia at the expense of the 
proper nervous tissue. Induration, or, as it is now generally 
called, sclerosis, is the result. Occasionally, however, the 
softening persists and becomes the permanent structural 
condition of the diseased portion of the cord. 

When the lesion is in the gray substance, the microscope 
shows the nervous cells to be broken up, and the anatomical 
elements of the blood to be scattered through the tissue. 

Treatment. — The treatment of acute myelitis offers no 
encouraging features. The most that can be done is to 
endeavor to prevent, as far as possible, the formation of 
sloughs, by placing the patient on a water-bed, and by 
sponging the parts exposed to pressure,with whiskey or with 
hot and cold water alternately applied. The treatment gen- 



462 DISEASES OF THE SPINAL COED. 

erally does not differ from that recommended in acute men- 
ingitis, the indications being almost identical. So far as 
my experience extends I have never found any means suffi- 
cient for cure, and the few successful instances that have 
been reported are doubtless, as Jaccoud suggests, cases of 
congestion or meningitis. 



CHAPTEE VI. 

SPINAL SOFTENING. 

Softening of the spinal cord is, as we have seen, the com- 
mon termination of acute myelitis, in which connection it 
has been sufficiently considered ; but it may originate pri- 
marily, and in that event possesses a clinical history very 
distinct from that of acute inflammatory softening. 

Symptoms. — The first symptom usually noticed in soften- 
ing of the spinal cord is numbness in those parts of the body 
below the seat of the lesion. Soon after the occurrence of 
this symptom there is weakness of the same parts, and then 
the deficiency of sensation and the feebleness of motor power 
advance together, both gradually becoming more and more 
strongly marked. There are no muscular twitchings, no 
contractions of the limbs, no pains either at the seat of the 
disease or in the paralyzed limbs. 

The bladder very soon becomes involved, and the patient 
finds that, when he attempts to urinate, the stream is not so 
strong as it once was, and that he is obliged at times to use 
the expulsive force of the abdominal muscles in order to 
complete the evacuation of the bladder. Gradually the con- 
tractile power of this viscus becomes less, and finally is alto- 
gether lost. 

The sphincter generally participates. The desire to 
urinate becomes more frequent, and when the inclination is 
felt the patient must at once yield to it. Eventually the 
bladder likewise becomes entirely paralyzed, and then there 



464 DISEASES OF THE SPINAL CORD. 

is neither the ability to expel the urine nor to retain it, and 
consequently it dribbles away constantly. 

Sometimes the first evidence of softening of the cord is 
perceived either in the bladder or its sphincter, and it may 
be restricted to these parts for a considerable period. I 
have a patient at the present time (February 9, 1871) under 
treatment for what I have no doubt is softening of the cord, 
and in whom the bladder-troubles were the only notable 
symptoms for over two years. 

The intestines are similarly affected, and the bowels are 
either obstinately constipated or the sphincter ani is relaxed, 
leading to fecal evacuations as soon as the contents reach 
the rectum. 

Reflex excitability is weakened from the first, and gradu- 
ally disappears, unless, as is rarely the case, the gray matter 
be unaffected. 

The progressive advance of the disease reduces the pa- 
tient to a condition of utter helplessness. He is unable to 
walk, sensation is abolished in the paralyzed limbs, his urine 
and fseces are passed involuntarily, bed-sores occur, the vene- 
real appetite is extinct, or, if it should remain, erections are 
impossible, and the parts of the body below the seat of the 
disease are to all intents and purposes cut off from commu- 
nication with the parts above. This condition may last for 
years without a fatal termination ensuing, but intercurrent 
affections, especially resulting from the bladder-difficulties, 
may eventually cause death. 

Such is the course of spinal softening when the lesion is 
low down and involves both antero-lateral and posterior col- 
umns. When it is higher up, the symptoms are also refer- 
able to the thoracic extremities, and to the muscles con- 
cerned in deglutition and respiration. There are likewise 
visceral disturbances. 

When the lesion mainly affects, or is confined to the 
antero-lateral columns, the symptoms manifested are in inti- 
mate relation with the known physiological functions of the 



SPIXAL SOFTENING. 465 

region in question. Thus the power of motion in the limbs 
below the softened portion of the cord gradually becomes 
less, the gait is from the first staggering, and though even at 
a late stage the patient may be able to move his limbs while 
lying down or sitting, he cannot support the weight of his 
body upon them. When he tries to stand without extrane- 
ous aid, it is seen that he is especially weak in the knees 
and ankles. There is no more difficulty in standing or walk- 
ing with the eyes shut than when they are open. 

This paralysis of motion, in which the bladder generally 
participates, may be of the most profound degree, and yet 
sensibility be perfect. A gentleman was under my care in 
whom I diagnosticated softening of the cord in that part 
extending on the right side from the second dorsal vertebra 
downward probably as far as the fourth sacral, while on the 
left side it began at about the fourth lumbar and extended 
downward probably as low as the fourth sacral. I gave the 
lesion these topographical limits for the reason that on the 
right side the muscles supplied by the crural and sciatic 
nerves had lost their electro-muscular contractility, while it 
certainly did not extend above the origin of the ilio-hypo- 
gastric nerve, as the lower part of the rectus abdominis, 
which receives its motor power through this nerve, retained 
its contractile power. On the left side the muscles supplied 
by the crural were possessed of their normal motor power, 
while those supplied by the sciatic had lost their contractility. 
It was, therefore, very certain that on this side the lesion 
did not extend above the fourth lumbar, the lowest spinal 
nerve contributing to the formation of the crural. 

I was able also to restrict the morbid process entirely to 
the anterolateral columns, for in no part of the skin below 
the upper supposed limit of the lesion was there any loss of 
sensibility. The least impression made upon the skin was 
felt. Tickling the sole of the foot excited laughter, but no 
reflex movements. I was therefore able to determine that 
the gray matter was involved. The bladder was paralyzed, 
30 



466 DISEASES OF THE SPINAL CORD. 

and its sphincter likewise. The sphincter ani was also de- 
prived of its contractile power to a great extent. 

The patient died at Cape May, and I had no opportunity 
of making a post-mortem examination. There can be no 
doubt, however, that the lesion was essentially that which I 
have described. In all cases of spinal softening involving 
the antero-lateral columns, the electro-muscular contractility 
is soon lost, so that even the strongest induced or primary 
currents fail to cause contractions. 

As regards the implication of the posterior columns, 
there is an equal facility for determining the fact from a 
consideration of the symptoms. The functions of these col- 
umns are intimately connected with sensation, and when 
such a morbid process as softening is set up in them the 
symptoms are those which indicate impairment of the cuta- 
neous and muscular sensibility. Thus, in a gentleman now 
under my charge, there has been going on for several 
months a morbid action in the spinal cord unattended by 
any prominent symptoms except anaesthesia. There has 
never been pain or any derangement of motility, but simply 
a gradually-increasing loss of sensibility in both lower ex- 
tremities and in all the other parts of the body below the 
upper limit of the seat of the lesion. 

He is unable to walk in the dark or with his eyes shut, 
or to stand alone with his eyes closed and his feet close 
together, for he obtains no idea of his position unless he can 
have the aid of his eyes or hands. 

He has full power over the bladder and voluntary con- 
trol over its sphincter and that of the rectum, but he never 
experiences the desire to urinate, does not feel the flow of 
urine through the urethra, nor the passage of the faeces 
through the anus, and evacuates his bladder and bowels at 
stated periods merely from the knowledge acquired by ex- 
perience that it is time to do so. 

Examination with the sesthesiometer shows that the up- 
per limit of the lesion on both sides is in that part of the 



SPINAL SOFTENING. 467 

cord from which the second lumbar nerves are derived, for 
the loss of sensibility is apparent in all those parts supplied 
by the crural and sciatic nerves, both as regards the skin 
aud the muscles. Yery weak faradaic currents cause mus- 
cular contractions, but the strongest which it is possible to 
obtain from a powerful machine produce no pain. 

In this case there is, I think, ample reason to diagnosti- 
cate a lesion of the posterior columns without any implication 
of the antero-lateral. The reasons for believing this lesion 
to be softening will be indicated under the head of diagnosis. 

Causes. — The causes of spinal softening are not very 
clearly understood. Doubtless it arises as a consequence 
of acute myelitis, but it is often an independent and appar- 
ently a primary affection, being unpreceded by any obvious 
symptoms indicative of spinal derangement. Such influ- 
ences as give rise to cerebral softening will, in all probabil- 
ity, cause spinal softening, and among them must be placed 
obliteration of blood-vessels from embolism and thrombosis. 
The actual occurrence of occlusion of spinal vessels from 
either of these causes has not, however, so far as I am 
aware, been demonstrated. The further etiology of spinal 
softening is not as yet a matter of any certainty, though I 
think several cases that have been under my observation 
could reasonably have their cause laid to excessive sexual 
indulgence. 

Diagnosis. — The diagnostic marks of most value in cases 
of supposed spinal softening are the absence of sensory and 
motor excitement. Thus there are no pains referable to the 
back or other parts of the body, no hyperesthesia, no twitch- 
ings, no spasms, no contractions, no exalted reflex actions. 
And this is the case in that form of the disease involving 
the whole thickness of the cord, or in either of those limit- 
ed to the anterior or posterior columns. There is no other 
affection of the spinal cord which is not characterized, at 
some time or other of its progress, by irritation either of the 
sensory or motor nerves, or of both, excepting some cases 



468 DISEASES OF THE SPINAL CORD. 

of spinal anaemia giving rise to the categories of symptoms 
previously considered. The clinical history of snch cases, 
and the comparatively light character of the phenomena, 
will serve to distinguish them from those in which the lesion 
is softening. 

Prognosis. — The prognosis is always unfavorable as re- 
gards recovery and complete restoration, but spinal soften- 
ing is not necessarily a fatal disease. At least I have seen 
cases which had existed for many years, and which appar- 
ently had no elements of a fatal termination about them. 
But they were instances in which the seat of the disease 
was in the lower dorsal, or lumbar or sacral region of the 
cord. When it is higher up, the prospect of death ensuing 
is more probable. The restoration of the cord to its normal 
structure is impossible, and the patient lies paralyzed either 
in sensation or motion, or both, according to the situation 
and extent of the lesion, in a condition similar to that of a 
person who has received a wound inflicting irreparable in- 
jury on the cord. Such persons, as is well known, fre- 
quently live for many years afterward — then die of some 
entirely different disease. There is nothing about spinal 
softening calculated to produce exhaustion, unless it be the 
tendency which exists to cystitis from paralysis of the blad- 
der, and the consequent inflammation liable to be set up 
from the action of the retained urine. Care, however, will 
very greatly diminish the danger from this source. I have 
had a number of patients under my charge who had not, 
for many years, had a passage of urine from the bladder 
which was not effected with the catheter, and they had, in 
all that time, suffered no marked inconvenience. 

Morbid Anatomy and Pathology. — The appearance of a 
softened portion of the spinal cord to the naked eye has 
nothing very peculiar about it. When examined as to its 
consistence, it is seen to be sometimes as soft as cream, at 
others scarcely altered in the resistance which it offers to 
the touch. In the first instance, when the lesion involves 



SPINAL SOFTENING. 469 

the gray and white matter together, section does not show 
the peculiar double cresentic arrangement of the former tis- 
sue, but it appears to be blended homogeneously with the 
white substance which surrounds it. 

Microscopically it is seen that the nervous tubules con- 
stituting the essential anatomical elements of the white sub- 
stance are broken up, and no vestige of them remaining in 
extreme cases — oil-globules and bodies called granule-mass- 
es, the constituent of which is fat, having taken their place. 
In the gray substance the nervous cells are destroyed, and 
oil and fat have made their appearance in large amount. 
Even the neuroglia or connective tissue of the cord exhib- 
its a similar disintegration and regressive metamorphosis. 
These changes impair the functions of the cord, both as a 
nervous centre and as a structure serving for the transmis- 
sion of sensory impressions to the brain, and of nervous 
force from it. When the disintegration is complete, the 
effect is the same as if the cord had been entirely divided 
by a cutting instrument. 

Treatment. — There is nothing to be done which can by 
any possibility restore the integrity of the spinal cord after 
the process of softening has fairly entered upon its course. 
In the very early stages, if patients apply for treatment at 
these times, something may perhaps be accomplished by 
the use of phosphorus and strychnia, but the symptoms 
come on so insidiously and gradually that the subject of 
them rarely has his apprehensions excited till it is too late 
to do any thing toward arresting the disease. And even 
when we do see cases which in appearance exhibit the symp- 
toms met with in spinal softening in its initial stage, and 
which recover under treatment, there must always be a 
doubt in regard to the accuracy of the diagnosis — for many 
cases of temporary anaesthesia and impairment of motility 
are due to anaemia of the cord, the result of the causes set 
forth in a previous chapter. 

The patient, however, may be made comfortable to such 



470 DISEASES OF THE SPINAL CORD. 

an extent as to materially prolong his life. Care should to 
this end be taken that he does not sustain a fall or suffer an 
injury whereby the diffluent portion of the cord would be 
disturbed in its anatomical relations, and the danger of an 
attack of acute meningitis or of myelitis incurred. Bed- 
sores should be prevented, or, if they occur, treated accord- 
ing to the methods previously mentioned, and full instruc- 
tions should be given in regard to emptying the bladder 
with the catheter at regular times, and of going to stool 
at the same hour every day. Locomotion may be provided 
for by some one of the chairs devised for the use of para- 
plegics. 



CHAPTEK VII. 

SCLEROSIS OF TEE ANTERO-LATERAL COLUMNS OF THE 
SPINAL CORD. 

Sclerosis affecting the antero-lateral columns of the spi- 
nal cord, whether it be diffused, multiple, or cortical, gives 
rise to symptoms which do not vary essentially with the 
form. It will therefore be advisable to consider them all 
under the present head, pointing out in the course of the 
description such distinctions as can be shown to exist. 

Symptoms. — In cases of sclerosis limited to the antero- 
lateral columns, there are no aberrations of sensibility either 
in excess or diminution, but as it very generally happens 
that there is more or less meningitis, pain may be experi- 
enced, or there may be different degrees of anaesthesia from 
the posterior roots of the spinal nerves being implicated. 
From the same cause acting on the anterior roots, twitch- 
ings and jerkings of the muscles and limbs below the seat 
of the lesion will be produced. The existence of pain, or 
of muscular contractions, in the early period of the disease 
is, therefore, always indicative of the fact that the mem- 
branes are involved in the morbid process. 

So far as the cord itself is concerned, the first symptom 
is loss of muscular power. At first the patient merely tires 
more readily, slight exertion fatigues him, and this is espe- 
cially noticed in the muscles which flex the leg on the thigh, 
and the consequent sensation of weariness experienced in the 
popliteal space. Sometimes it is shown in the sudden relax- 
ation of the extensor muscles of the leg, and the fall of the 



472 DISEASES OF THE SPINAL CORD. 

patient thereby ; at others, in the fact that the extensors of 
the foot become weak, allowing the toes to drop, and hence 
causing stumbling. The gait then becomes characteristic. 
Owing to the fact that the patient's extensor muscles are 
weak, he is unable to lift the feet high enough to cause them 
to clear the ground, and hence he throws them out by means 
of the abductor muscles of the thigh, and thus causes them 
to describe an arc of a circle. Then in putting them down 
the heel strikes the ground a longer time before the sole 
than it does in the natural gait, and hence the foot comes 
down with a jerking motion. This is the ordinary manner 
of walking practised by a person affected with the disease 
under notice. In another form of locomotion, the body is 
moved laterally on the thighs, first to one side and then to 
the other, in such a way as to cause the feet to be raised 
high enough without the complete action of the extensor 
muscles. The gait is therefore similar to that of a duck, or 
of a woman with a very wide pelvis. In a patient now in 
the JSTew York State Hospital for Diseases of the Nervous 
System, this method of progression is very strongly marked. 
The motion of the body is almost serpentine, and the feet 
glide over the ground barely lifted high enough to avoid 
contact. 

In both the methods of walking the patient requires sup- 
port. At first a cane answers, then he comes to crutches, 
and eventually the assistance of an attendant becomes ne- 
cessary. 

As a consequence of the paralysis, the movements are 
often complicated and sometimes rendered impossible by the 
legs becoming interlocked at every attempt to walk. In a 
patient from Connecticut under my care, not long since, this 
difficulty was a very prominent feature, and though the 
muscles of flexion and extension were sufficiently strong to 
allow of his walking, those which abduct the thighs were so 
materially paralyzed as to produce the condition mentioned. 

Reflex movements, so far from being lessened, are gener- 



ANTERO-LATERAL SPINAL SCLEROSIS. 473 

ally exalted, and this for the reason that sclerosis rarely 
affects to much extent the gray matter of the cord. Some- 
times this exaltation is so notable a feature as to cause great 
inconvenience. A gentleman now under my charge, with 
sclerosis of the antero-lateral columns, has no contractions of 
the limbs or even twitchings of the muscles, unless through 
the influence of an irritation applied to them. He has no 
voluntary power whatever over the lower extremities, and 
yet the slightest touch on the sole of the foot or side of the 
ankle is sufficient to cause powerful reflex movements in 
either leg. In another, in which the disease is not confined 
to the anterior columns, but which likewise extends to the 
posterior, the mere contact of a straw with the sole of the 
foot — an irritation not felt, for there is plantar anaesthesia 
— causes contractions to such a degree as to flex both the leg 
and the thigh to the utmost possible extent. 

The electro-muscular contractility is also usually in- 
creased. Under the influence of mild induced currents, 
every individual muscular fasiculus can be seen to contract, 
and, as the layer of fat under the skin is generally absorbed 
at an early period of the disease, the bundles of fibres can 
be very distinctly made out. 

But, although in the early stages of the disease there are 
no muscular contractions unless there is irritation of the an- 
terior roots of the spinal nerves coming from the affected 
portion of the cord, at a late period there may be involun- 
tary movements, due entirely to the sclerosis. These are 
the result of the implication of the fibres of origin of the 
nerves in the morbid process, and consist of fibrillary contrac- 
tions, twitchings of whole muscles, or jerkings of the limbs. 
They are manifested without being set into action by vol- 
untary movements, and therefore differ from, the twitchings 
observed in cases of cerebro-spinal sclerosis, and which are 
due to the association of the pons Yarolii or other cerebral 
ganglia in the disease. Tremor is, therefore, never observed 
in spinal sclerosis of any form, diffused, multiple, or cortical, 



474 DISEASES OF THE SPINAL CORD. 

unless the pons Yarolii or superior ganglia of the brain are 
implicated. In the only case of this latter form published 
— that of Yulpian * — the sclerosis extended throughout the 
whole length of the cord, and likewise involved the pons 
Yarolii, cerebellar, peduncles, and other intracranial organs, 
besides being accompanied by well-marked spiual menin- 
gitis. The tremor observed at a late period of the disease 
cannot, therefore, be ascribed to the lesion of the cord below 
the medulla oblongata. 

The relations of tremor to the other forms of spinal 
sclerosis will be further considered under the head of pathol- 
ogy 

Another symptom, indicating the extension of the mor- 
bid action to the origins of the nerves, is atrophy of the mus- 
cles deriving their nervous influence from nerves originating 
at the diseased portions of the cord. In the cortical form of 
the disease, we should not expect this symptom to be pres- 
ent, for the lesion affects only the superficial layer of white 
substance, nor is it for the same reason apt to exist in cases 
of multiple sclerosis of the antero-lateral columns. It is — 
and the same may be said of muscular contractions — almost 
peculiar to the diffused form of the affection. 

The bladder is often paralyzed, and hence the patient is 
obliged to use the catheter for the evacuation of the urine. 
The sphincter becomes involved at a later period. 

But it frequently happens that the bladder and sphincter 
both escape. A number of such cases have been under my 
charge, and in one still being treated, which has lasted sev- 
eral years, and in which both lower extremities are entirely 
paralyzed, the bladder and sphincter retain full power. In 
those cases in which they are not implicated, the morbid 
action does not penetrate deep enough to involve the origins 
of the nerves. 

The bowels are usually obstinately constipated at first, 

1 Note sur un cas de Meningite spinale et de Sclerose corticale annulaire de 
la Moelle Epiniere, Archives de Physiologie, No. 2, 1869, p. 279. 



ANTERO-LATERAL SPINAL SCLEROSIS. 475 

and throughout the whole course of the disease till toward 
the close, when incontinence from paralysis of the sphincter 
ani takes place. 

Sclerosis of the antero-lateral columns of the spinal cord 
is not a rapid affection, although its course is ordinarily 
progressively onward. Occasionally there are well-marked 
symptoms, and it often happens that medication produces, 
for a while, favorable results. The duration of the disease 
is from about two to five years. Cases have been reported 
in which death ensued within a few months, and I have 
a case now under my notice in which it has lasted twelve 
years, and in which, even now, the patient can walk tolera- 
bly well. Death takes place either from the extension of 
the morbid action, or from some intercurrent affection. 

The symptoms, of course, vary with the position of the 
lesion. When the upper region of the spinal cord is affect- 
ed, the superior extremities, and the parts of the body sup- 
plied with nerves from the diseased portion of the cord, par- 
ticipate. In a case which I first saw in consultation with 
my friend Dr. Walter F. Atlee, of Philadelphia, and which 
was subsequently for a long time under my immediate 
charge, the lesion was, in the beginning, confined to the 
very lowest part of the spinal cord. Gradually the disease 
extended upward, or new centres of sclerosis were formed, 
until at last, after three years, the muscles of deglutition 
and of respiration became implicated, and death took place. 
But for several months before this the patient was unable 
to use either legs or arms, or even to sit up. At no time, 
however, was the bladder deranged in any respect, and at 
no time were there pains or spasmodic action of the muscles. 
The cutaneous sensibility was scarcely affected, and there 
was no atrophy beyond that due to long-continued inaction 
of the muscles. No post-mortem examination was made, 
but there can be little if any doubt that the lesion was com- 
paratively superficial, and that it was almost entirely con- 
fined to the antero-lateral columns of the cord. 



476 DISEASES OF THE SPINAL CORD. 

In a similar case occurring in a distinguished legal gen- 
tleman of New Orleans, sent to me by my friend Dr. Cabell, 
of the University of Yirginia, there is a gradual extension 
of the disease upward without any attendant pains, anaes- 
thesia, or muscular contractions, except to a slight extent at 
first. In this instance, also, the bladder and rectum have 
escaped. That the lesion is superficial, and confined to the 
antero-lateral columns, I am very sure. 

In another case, that of a gentleman from New Jersey, 
there is a similar condition, but with the additional phe- 
nomenon of muscular atrophy. 

Such cases as the foregoing, and several others which 
have come under my notice, are doubtless to be classed with 
many of those placed under the head of what Duchenne 1 
has called general spinal paralysis — while others have been 
referred to softening of the antero-lateral columns of the 
cord. 

Causes. — Although sclerosis of the antero-lateral columns 
of the spinal cord may be due to an antecedent attack of 
acute myelitis, or one of meningitis, there is no doubt it is 
often a primary disease. 

Sex is certainly a predisposing cause; probably, how- 
ever, acting secondarily, from the fact that difference of sex 
almost necessarily implies difference in mode of life. Males 
are much more liable to the disease than females. Of the 
forty-eight cases that have been under my care, or in which 
I have been consulted during the past six years, forty-two 
were males. 

Age is also influential. Of the forty-eight cases, all 
were over the age of twenty-five, and none were over 
sixty. One was over fifty-five, three between fifty and 
fifty-five, seven between forty-five and fifty, and all the 
rest under forty-five, when the disease first manifested it- 
self. 

1 Paralysie gene rale spinale. De l'Electrisation localisee, etc. Paris, 1861, 
p. 258. 



ANTEROLATERAL SPINAL SCLEROSIS. 477 

Hereditary influence is undoubted in many cases; so 
far, certainly, as it is exerted by the ancestors having suf- 
fered from some form of nervous disease. In other instances 
there is the transmission of a direct tendency to the disease 
in question by some no very distant ancestor having had the 
same affection. 

Anions; the exciting causes are the excessive use of alco- 
holic liquors, inordinate sexual indulgence, exposure to se- 
vere cold, blows on the spine, and the gouty, scrofulous, or 
syphilitic diathesis. In the great majority of cases the 
cause is not apparent. 

Diagnosis. — There is rarely much difficulty in recognizing 
sclerosis of the antero-lateral columns of the cord ; for, as 
will have besn perceived, the symptoms are well marked. 
The only affection with which it is really liable to be con- 
founded is softening of the same region ; and here the fact 
that sclerosis is almost always accompanied by meningitis, 
and that therefore there is in the first stage evidence of 
sensory and motor excitation, will generally suffice to ren- 
der the diagnosis accurate. The gait of a person affected 
with sclerosis is, moreover, very different from that of one 
suffering from softening ; the course of the disease is slower, 
and the paralysis rarely so profound. Other diagnostic 
marks will be perceived from a consideration of the symp- 
toms of the two forms of chronic myelitis as I have described 
them. 

Prognosis. — The prognosis is always grave ; and, sooner 
or later, a fatal termination usually takes place. Still, 
great ameliorations are possible, and a cure is not im- 
possible. 

Morbid Anatomy and Pathology. — The essential feature of 
sclerosis occurring in the spinal cord is identical with that 
of the same condition affecting the cerebral hemispheres, and 
which has already been considered. It consists of hyper- 
trophy of the connective tissue and atrophy of the proper 
nerve-substance. A part of the cord which has undergone 



478 DISEASES OF THE SPINAL, CORD. 

this change presents features which are easily recognizable. 
Its color is changed to a yellowish gray, and its consistence 
is much increased. At the same time there is a decided 
condensation, so that the circumference of the cord is les- 
sened. As already stated, sclerosis appears in the spinal 
cord under three forms. In one of these, called diffused 
sclerosis — the sclerose uniforme of Jaccoud — the lesion oc- 
cupies a considerable extent of the tissue, and may involve 
the whole thickness of the cord throughout its entire 
length. In another multiple or disseminated sclerosis — the 
sclerose en plaques disseminees of Charcot and the sclerose 
diffuse of Jaccoud — the lesions are several in number and 
are entirely isolated. In the third, cortical sclerosis — the 
sclerose corticale annulaire of Yulpian — the lesion is 
confined to the superficial layers of the cord. In which- 
ever of these forms the lesions exist, they are marked by 
white striae, which are the proper nerve-filaments, still 
presenting somewhat their characteristic color and consist- 
ence. 

The membranes often exhibit evidences of inflammation, 
and are thickened, opaque in spots, or red in some cases, 
while in others they are adherent to each other and to the 
cord. 

When submitted to microscopical examination, the scle- 
rosed tissue is seen to consist mainly of an excessive amount 
of connective tissue — the neuroglia of Virehow. The cells 
are increased in size, and the nuclei are larger and much 
more numerous than in the normal condition. The capil- 
laries are thickened, from the deposition on their walls oi 
several layers of rounded cells. 

The effect of this morbid process is to compress the 
nervous filaments and to cause their atrophy. The fluid 
portion undergoes fatty degeneration, and the axis cylinders 
become disintegrated. 

In a case of sclerosis of the antero-lateral columns of the 
spinal cord, which was for a time under my care, I have 



ANTERO-LATERAL SPINAL SCLEROSIS. 479 

recently had the opportunity of making a careful examina- 
tion of the diseased portions. 

The patient, J. H., consulted me in the winter of 
1869-70. He was then unable to walk without a cane and 
the assistance of an attendant. He had previously been 
treated at a water-cure establishment, and more recently by 
the Swedish movement-cure, and of course without benefit. 
The symptoms were mainly connected with motility. Both 
lower extremities were paralyzed ; the bladder was inactive, 
but not the sphincter, and there was obstinate constipation. 
There were occasional fibrillary contractions of the para- 
lyzed muscles, and at times pain in the back and limbs — 
never, however, of any great degree of severity. There 
were no tremors, either with or without voluntary motions. 

The patient obtained very little benefit from the treat- 
ment to which I subjected him, and I advised him to return 
to his home in Ohio. A few months afterward, he died. 

The dorsal, lumbar, and sacral regions of the cord 
were sent to me for examination by his physicians, Drs. 
Ramsey and Bishop, of Delhi, Ohio. In a letter, the latter 
informed me that the vessels of the pia mater were injected. 

The cord arrived in good condition, having been care- 
fully preserved in strong alcohol. Upon inspection, the 
antero-lateral columns in the middle and lower dorsal regions 
to the extent of three and a half inches were seen to be of 
a grayish tint, which became deeper in shade from above 
downward. Below this, at the junction of the dorsal with 
the lumbar portion, was another patch two and a half inches 
in length, and also involving the whole superficies of the 
antero-lateral columns ; and, separated from this by a por- 
tion of apparently healthy tissue, was another discolored, 
irregular patch, an inch and a half in length, along the left 
antero-lateral column ; and, below this, a similar tract, two 
inches and an eighth long, involving the right antero-lateral 
column. The difference in consistence between these 
patches and the other parts of the cord was very decided, 



480 DISEASES OF THE SPINAL CORD. 

and the white striae were well marked. The sacral portion 
of the cord presented no abnormal appearance to the 
naked eye. 

Sections of the cord were then made through the scle- 
rosed portions ; and it was seen that the gray matter was 
only involved where the horns approached the surface; and 
that, wherever a lesion existed, the normal contour of the 
sections was altered so as to make them sub-ovoidal, and 
thus to lessen the circumference. The greatest depth of any 
part of a sclerosed region was two-twelfths of an inch, and 
this was in the superior patch. The average thickness was 
about the one-twelfth of an inch. 

The whole cord in my possession was then immersed in 
a solution of chromic acid in water, and left there for a 
month to harden. Immediately previous to examining 
with the microscope, the sections were colored by an 
ammoniacal solution of carmine. Under a twelfth-inch 
objective, it was seen that, throughout the whole extent of 
the sclerosed portion of any section, the nerve-tubes had 
entirely disappeared; and, wherever the gray substance 
was affected, the nerve-cells were diminished in number. 
In the place of these elements was connective tissue, a large 
quantity of molecules, and connective-tissue cells in great 
abundance. 

In several sections taken from the dorsal, lumbar, and 
sacral regions, and which were apparently normal when 
viewed with the naked eye, the neuroglia was found 
to be in excess, and the nerve-tubes in a state of disinte- 
gration. 

The gray matter, except in those sections made through 
the part where the sclerosed portion extended from the white 
matter to it, was uniformly healthy, and in no part were the 
posterior columns involved. 

In this case there was no tremor, although it was clearly 
one of multiple sclerosis, probably entirely confined to the 
spinal cord. At no time had there been head-symptoms of 



AXTERO-LATERAL SPINAL SCLEROSIS. 481 

any kind. I think, therefore, that Dr. M. Clymer ' is in 
error, where he states, under the head of "Disseminated 
Sclerosis of the Spinal Form," that "rhythmical spasms 
accompany any voluntary movement of the affected muscles." 
As previously stated, I am ot opinion that such movements 
are only present when the affection has also attacked the 
central ganglia — and, indeed, the cases cited by Dr. Clymer, 
in the appendix to his excellent memoir, abundantly sustain 
this view ; for, of the sixteen cases tabulated by him, tremor 
is not stated to have occurred in any one in which the lesion 
was limited to the cord. 

In the case of Dr. Pennock, reported by Drs. Morris and 
S. Weir Mitchell, 1 the sclerosed tissue was confined to the 
spinal cord and mainly to the lateral part of the anterolat- 
eral columns. The posterior were involved to a very small 
extent. In this case there were partial anaesthesia, gradu- 
ally advancing paralysis implicating all four extremities, 
and paralysis of the bladder. The intellectual faculties 
were never affected in the least. The course of the disease 
was progressively onward, and, though there was toward the 
last a total loss of voluntary power below the neck, reflex 
action remained unaffected. There were no tremors with 
or without voluntary movements. In regard to this case, 
Dr. Mitchell, who made the microscopical examination, re- 
marks that there were : 

" 1. Integrity of mental and moral manifestations. 

2. Absolute loss of voluntary motive power below the 
head, or rather below the neck. 

3. Sensation nearly perfect. 

4. Respiration good; reflex motion preserved and ex- 
hibited in the form of spasm or irritation of certain parts of 
the skin." 

All of which are what we should expect to find in scle- 
rosis almost entirely confined to the antero-lateral columns. 
In the description of the disease as given by several au- 

1 Op. cit., p. 12. 2 American Journal of the Medical Sciences, July, 1868. 

31 



482 DISEASES OF THE SPINAL CORD. 

thors, great stress is laid on the occurrence of violent tonic 
contractions of the limbs. As the reader, however, will 
have inferred, these are not due to the sclerosis, but result 
from the meningitis which is often an attendant condition. 

Treatment. — The indications are in the first stage to di- 
minish the amount of blood in the vessels of the meninges 
and of the cord, and with this view, when I see a patient ex- 
hibiting the early symptoms of sclerosis, I prescribe large 
doses of ergot as recommended for spinal congestion. The 
results have been exceedingly favorable, and I think it very 
probable that by this treatment the advance of the disorder 
has been checked. But in those insidious forms of the affec- 
tion not accompanied in the early stage by symptoms indi- 
cating hyperemia, and in those cases in which the morbid 
process has apparently reached that stage in which there is 
proliferation of the neuroglia, ergot can be of no service. On 
the contrary, by lessening the amount of blood in the cord, 
and hence interfering with its nutrition, it is calculated to 
do harm. At this period I am inclined to think more 
benefit is to be derived from nitrate of silver, cod-liver 
oil, and the primary galvanic current, than from any other 
measures. 

In Dr. Pennock's case it is stated that the water-cure 
was tried for a time with some temporary benefit, and Jac- 
coud declares that hydrotherapy and mineral waters are still 
the most efficacious remedies. My experience is not to this 
effect. Several of my patients had, before coming under 
my charge, made use of the means in question, but never 
with the least favorable result. Even the Turkish bath, 
which is so useful in some affections of the nervous system, 
does harm in this. I have in a number of instances seen all 
the symptoms aggravated by two or three such baths. 

Counter-irritation I have employed repeatedly in all its 
forms, but never with the slightest benefit. 

For the relief of any pain that may be present, codein 
in the dose of half a grain or more is to be preferred. Should 



ANTERO-LATERAL SPINAL SCLEROSIS. 483 

there be the least suspicion of syphilis, mercury and iodide 
of potassium, as recommended on page 322, should be used 
and continued for several weeks before it is deemed ineffica- 
cious. 

The bladder should always be looked after if there is any 
paralysis, and the patient instructed to use the catheter at 
stated periods. 



CHAPTER VIII. 

SCLEROSIS OF TEE POSTERIOR COLUMNS OF THE SPINAL 
CORD {LOCOMOTOR ATAXIA). 

Although other writers, and especially Romberg, 1 had 
described a disease answering to that now generally known 
as locomotor ataxia, we are mainly indebted to Duchenne a 
for giving a full and distinct account of an affection which, 
before his studies, had scarcely attracted attention. In ac- 
cordance with the plan pursued in the present work, of des- 
ignating diseases as far as possible by the lesion, and not by 
the symptoms, I have decided to use the proper pathological 
term for the affection under question, even though it be not 
so familiar as the one usually employed. 

Symptoms. — Posterior spinal sclerosis has no uniform set 
of initial symptoms. Sometimes it begins with dull, heavy 
pains in the small of the back or other part of the spinal 
column, which are very soon followed by sharp, electric-like 
pains, which shoot down the limbs along the course of the 
nerves, and which are very generally taken by the patient 
for twinges of neuralgia or rheumatism, or it may be first 
manifested by a feeling of constriction around the body like 
that which is so common in acute myelitis. 

Again, the first symptoms are cerebral, and may consist 
of attacks of vertigo, epileptic fits, disturbances of vision, 
such as diplopia, ptosis, and defective accommodation. 

1 Lehrbuch der Nervenkrankheiten, Berlin, 1840; also Sydenham Society's 
Translation, London, 1853. 

2 De l'Ataxie locomotrice progressive, Arch. Gen. de Med., 1858 ; also De 
l'Electrisation localisee, Paris, 1861. 



POSTERIOR SPINAL SCLEROSIS. 485 

At other times the stomach and bowels are disordered ; 
vomiting is frequent, and there may be diarrhoea or obstinate 
constipation. Or, finally, the initial phenomena may be 
connected with the sensibility, giving rise to anaesthesia, 
and the various abnormal sensations connected therewith. 

In whatever way it may begin, posterior spinal sclerosis 
is soon chiefly manifested by disorders of motility, but in- 
quiry reveals the fact s that these are in reality secondary, 
being dependent upon the diminished sensibility which al- 
ways exists. As this is the essential feature of the disease, 
I propose, to inquire into its characteristics at some length. 

If the lesion, as it usually does, exists in the dorso-lumbar 
region of the cord, the first evidences of anaesthesia or of 
perverted sensibility are noticed in the feet. A common 
feeling is one as if the toes are too large for the shoe, or as 
if pieces of some plastic material are between them. Some- 
times there are burning pains in the soles of the feet, and 
very generally " pins and needles " and other forms of 
numbness. A curious symptom is that, not only is the sen- 
sibility lessened, but the transmission of sensitive impres- 
sions to the brain does not take place with the normal de- 
gree of activity. I have noticed this phenomenon in rather 
more than half the cases that have come under my obser- 
vation. In a lady, now a patient, a pin stuck into the calf 
of the leg is not felt for fourteen seconds on the right side 
and sixteen on the left. In a patient with posterior spinal 
sclerosis, under treatment in the New York State Hospital 
for Diseases of the Nervous System, if the feet are put into 
hot water the sensation is not felt for almost three minutes. 
As he said, " My feet might be scalded till the flesh dropped 
off and I would not know it till the mischief was done. 
Then I should feel it sharply." The explanation of this 
symptom is to be found in the fact that the conducting 
power of the posterior columns is lessened by the lesion, and 
hence the brain does not receive in the usual time the im- 
pressions made upon the nerves. 



486 DISEASES OF THE SPINAL CORD. 

The ability to feel pain is therefore diminished, but there 
is, besides, a marked abatement of the tactile sensibility. 
The extent of this can only be accurately measured by the 
sesthesiometer. When this instrument is used, we find that 
the two points can be widely separated and a single im- 
pression only be felt on parts of the body which in the nor- 
mal condition would give the sensation of two points at a 
much less distance apart. A gentleman from Virginia con- 
sulted me recently, in whom I diagnosticated posterior spinal 
sclerosis, and who, instead of being able to perceive the two 
points with the end of the index-finger, when the twelfth 
of an inch apart, could feel but one point, though the two 
were separated to the extent of an inch and a half. 

This loss of sensibility gives rise to some curious sensa- 
tions, especially in the soles of the feet. These are usually 
such as might be produced by the interposition of some sub- 
stance between the foot and the shoe, or between the shoe 
and the ground. One patient feels as if he has cushions on 
the soles of his feet, another as if bladders of air are inter- 
posed, another as if he is constantly treading on sticks, or, 
if riding in an omnibus, as if the hem of a lady's dress had 
got under his feet, and one a short time since described the 
sensation to me as being like that which he thought he 
would feel if his feet had been dipped into tar, and then 
into sand. 

In some cases the ability to distinguish differences of 
temperature, or to appreciate the sensations produced by the 
application of hot or cold bodies to the skin of the affected 
parts, remains, but this is not, as some authors assert, a con- 
stant phenomenon, for in the majority of cases the sensa- 
tions produced by heat or cold are just as unappreciable as 
those caused by any means capable of giving rise to sensitive 
impressions. 

But the symptoms by which a person with sclerosis of 
the posterior columns of the spinal cord is recognized most 
readily are those which relate to motility, and these phe- 



POSTERIOR SPINAL SCLEROSIS. 487 

nomena often make their appearance at a very early stage of 
the affection. At that time there is no loss of motor power, 
but there is an inability to coordinate the muscles — to bring 
them into harmonious action, and thus to execute with pre- 
cision the various voluntary movements. Thus, in the act 
of standing, a great many muscles are simultaneously made 
to contract, and each one to just that necessary degree which 
is essential to maintaining the body in the erect posture. 
Yery often the first evidence of any motor difficulty is ex- 
perienced in regard to this faculty of standing. This diffi- 
culty is, however, not one of paralysis, for, if the patient 
looks at his feet, he has no more trouble in standing alone 
than a perfectly sound man. 

A gentleman connected with the city government of 
Brooklyn consulted me a short time since for an affection 
which was very evidently posterior spinal sclerosis. The 
first indication of disease, as he informed me, was that it 
had been his habit, while at his morning ablutions, to shut 
his eyes, and he had noticed, about two months previously, 
that when he did so he could not maintain his equilibrium. 
When he visited me he was unable to stand with his eyes 
shut, and his gait was perfectly characteristic of posterior 
spinal sclerosis. 

Before the locomotion of the patient becomes obviously 
affected, he experiences inconvenience in placing his feet 
upon small surfaces. Thus, when he attempts to enter a 
carriage, he finds it difficult to guide his foot to the step, 
and in mounting a horse he cannot readily hit the stirrup. 
A gentleman from Maryland, who is now a patient of mine, 
and who is affected with the disease in question, tells me 
that among the first symptoms which he noticed was the 
difficulty he experienced in putting his foot into the stirrup. 
He was obliged to use his hand as a guide. A like trouble 
is frequently experienced in ascending a staircase. 

The gait of a person suffering from sclerosis of the pos- 
terior columns of the spinal cord is very much changed from 



483 • DISEASES OF THE SPINAL CORD. 

that which is natural. Instead of the foot being placed upon 
the ground with an easy motion, the heel a little in advance 
of the sole, and the latter gliding down gently, the ]eg is, as 
it were, jerked forward, the heel comes down suddenly, and 
the sole follows, at a considerable interval, with an abrupt 
flapping motion. In ordinary walking the placing of the 
foot on the ground consists of one movement — there being 
no stoppage between the touching of the ground by the heel 
and the planting of the sole of the foot ; but, in the gait of a 
person affected with posterior spinal sclerosis, the foot is 
placed on the ground by two distinct movements, one. for 
the heel and another for the sole of the foot. 

But, besides these irregularities of the progressive move- 
ments, there are others which are likewise notable. The leg 
is not carried directly forward, but is thrown out a little 
from the median line, and this gives the patient a motion 
like that of one walking on a tight-rope, and balancing him- 
self with a pole. The object of this movement is doubtless 
to widen the base, and thus to enable the patient to preserve 
more readily his centre of gravity within it. In standing, 
he, for the same reason, always separates the feet to a great- 
er than normal distance. 

In walking or standing, it will be observed that the pa- 
tient affected with posterior spinal sclerosis keeps his eyes 
fixed on his feet, or on the ground a little distance in ad- 
vance. He is obliged to do this for the reasons — which with 
others will be more fully considered under the head of pa- 
thology — that the sensibility of the soles of the feet being 
diminished, and the muscular sensibility being also lessened, 
he is deprived, to a great extent, of the chief means by which 
he was formerly enabled to recognize the position of his feet, 
and of the dynamic condition of his muscles. He hence is 
obliged to make use of another sense — his vision — in order 
to obtain the necessary information. Therefore, when he 
shuts his eyes, or is obliged to walk in the dark, he is de- 
prived of the assistance of his eyesight, and, having only his 



POSTERIOR SPINAL SCLEROSIS. 489 

diminished tactile and muscular sensibility to guide him, 
moves in an exceedingly timid and disorderly manner, or 
else is unable to walk at all. 

Under some circumstances he is unable to go forward, 
even with the assistance of his eyesight. Experience has 
taught him that he cannot rely on very important senses 
which formerly he implicitly trusted. He loses confidence 
in them, and is not reassured, even with vision to assist him. 
He therefore uses extraordinary caution in walking over a 
tiled floor, on the ice or snow, in descending a staircase, or 
in crossing a street crowded with vehicles. In a recent 
clinical lecture 1 delivered to the class of the Bellevue 
Hospital Medical College, I called special attention to this 
phenomenon of loss of confidence, and adduced several cases 
in illustration of this point. 

That there is little paralysis of motion to account for 
these abnormalities, can be readily shown by a few inquiries 
and experiments. Thus it will ordinarily be found that the 
patient who is unable to stand with his eyes shut or take a 
step in the dark, can push strongly with his legs, or walk a 
short distance with a good deal of vigor. He is still good 
for a " spurt," but long-continued muscular effort fatigues 
him. 

When the lesion is above the origin of the nerves which 
go to form the brachial plexus, the upper extremities are 
the seat of symptoms which are similar to those described as 
manifesting themselves in the legs. There are numbness 
and other indications of anaesthesia, together with more or 
less difficulty in coordinating the muscles into harmonious 
action. The patient finds that the ends of his fingers have 
lost, to some extent, their acute tactile sensibility, and that 
there is restraint in the management of the fingers. He 
experiences these difficulties in buttoning his clothes, in 
picking up a pin, in writing, and in other actions requiring 

1 Clinical Lectures on Diseases of the Nervous System. Journal of 
Psychological Medicine, January, 1871. 



490 DISEASES OF THE SPINAL CORD. 

nice manipulation. If he attempts, for instance, to carry a 
glass of wine to his lips, he spills a portion of the contents ; 
and, if told to place his finger on any particular part of 
his face, the movement is accomplished with a wabbling 
motion, and the linger is darted suddenly to the part as 
it approaches it. All persons possess a knowledge of where 
the different parts of their bodies are situated, which does 
not depend upon the sense of sight, although probably 
acquired by that sense and experience. There is such an 
intimate and exact relation between the ends of the fingers 
and the cutaneous surface of the body that, if a spot no 
bigger than the head of a pin be made with a pencil on the 
forehead, a person can close his eyes and touch it with the 
end of his finger without difficulty every time he makes the 
attempt. He can also, with the eyes shut, carry the end of 
his fingers straight to the tip of his ear, the middle of his 
eyebrow, or any other part of his body within reach. A 
person, however, laboring under sclerosis of the posterior 
columns of the spinal cord, cannot do any of these things. 
He loses, at a very early period of the disease, that intimate 
topographical relation which exists between the ends of the 
fingers and the rest of the body ; and hence, when he closes 
his eyes, and attempts to put the tip of his index-finger on 
the end of his nose, he misses his aim, sometimes by as much 
as two or more inches. 

As in the legs, when the lesion is so low down in the cord 
as only to affect them, there is no well-marked paralysis. 
The grip of the patient is strong, and the dynamometer 
shows the existence of considerable strength. He is, 
however, not capable of continued muscular effort; and, 
though he may be able to lift several hundred pounds, or to 
carry another person around the room, his muscles are ex- 
hausted with the gradual and regular expenditure of a much 
less amount of force. 

A phenomenon is often noticed as regards the upper 
extremities, which also exists with the lower, but which 



POSTERIOR SPIXAL SCLEROSIS. 491 

cannot be so readily manifested — and that is, that the patient 
loses the ability to distinguish even considerable differences 
between weights. In the normal condition, if two weights 
differing in the ratio of thirty -nine to forty, are put one in 
one hand and one in the other, the difference is perceived 
without difficulty. The lower extremities, according to 
Jaccoud, are not so sensitive, and cannot distinguish a less 
difference than from about fifty to seventy grammes. 

A person affected with posterior spinal sclerosis may have 
an ounce- weight put into his hand, and if in a few seconds it 
be removed, and one of half an ounce substituted, he will 
not be able to tell correctly which is the heavier. Or both 
hands may be extended, and the two weights placed simul- 
taneously in them. The eyes should, of course, be closed. 
Sometimes less differences can be perceived, but ordinarily 
greater ones are not distinguished. In the case of a gentle- 
man now under my charge, there is an impossibility of 
telling which of two pieces of lead, the one weighing one 
ounce and the other a pound, is the heavier. Spath * states 
that, in a case under his charge, the patient could not dis- 
tinguish between two weights, which differed as one to one 
hundred. 

No means for measuring the extent to which the patient 
is able to determine the state of muscular contraction is at 
all comparable to the dynamograph. The range of its useful- 
ness is, however, limited — owing to the fact that posterior 
spinal sclerosis is not very frequently seated high enough 
in the cord to affect the muscles of the upper extremities. 
'When the lesion is not above the origin of the nerves which 
go to form the brachial plexus, the line is straight, as in the 
accompanying figure : 

Fig. 22. 

which represents the tracing made by a patient suffering 
from posterior spinal sclerosis of the lower dorsal region of 

1 Beitrage zur Lehre von der Tabes dorsualis. Tubingen, 1864. 



492 



DISEASES OE THE SPINAL CORD. 



the cord. But, when the seat of the disease in the cord is 
anywhere between the fifth cervical and first dorsal verte- 
brae, the ability to maintain a uniform degree of pressure is 
impaired, and lines resembling the following are produced : 



Fig. 23. 




Both the above were made by the same patient, the upper 
with the right and the lower with the left hand. He was 
pefectly confident, till I showed him the tracings, that he 
had exerted a uniform pressure while the paper was travers- 
ing the pencil. 

Under the name of baraesthesiometer, Eulenberg 1 has re- 
cently described an instrument for estimating the sense of 
pressure, by means of which very accurate determinations 
can be made for different parts of the body. He succeeded 
in demonstrating a considerable impairment of the sense of 
weight in the great majority of cases of locomotor ataxia 
examined, even when sensibility to pain, tickling, or electric 
irritation, was but slightly affected, and the sense of tem- 
perature was normal. 

The reflex power is generally notably increased. The 
touch of the bedclothes, or even the rubbing of one leg 
against the other, is sufficient to cause powerful contractions. 

1 Allg. Med. Cent. Zeitung, No. 93, 1869. Also Journal of Psychological 
Medicine, October, 1870, p. 622. 



POSTERIOR SPINAL SCLEROSIS. 493 

Involuntary movements of the limbs, independent of those 
due to reflex excitations, are rarely met with. 

The electro-muscular contractility is always increased. 

It has already been mentioned that there are frequently 
ocular troubles. These generally occur among the first 
symptoms, and relate either to vision, to the movements of 
the eyeball, or to both. Thus there may be amaurosis due 
to atrophy of the optic nerve, or of the disk, a condition 
readily detected by the ophthalmoscope. Or the third pair 
of nerves may be involved, causing ptosis, divergent stra- 
bismus, and dilatation of the pupil ; or the sixth pair of 
nerves alone may be affected, causing convergent strabismus ; 
or there may be only dilatation of the pupil and prominence 
of the eyeball from the irritation propagated from the cilio- 
spinal centre through the sympathetic nerves. These ocu- 
lar troubles never take place in posterior spinal sclerosis ex- 
isting below the cilio-spinal centre — the upper dorsal region 
of the cord. The disturbances in the healthy action of the 
stomach and intestines, which have already been alluded 
to as common initial symptoms, are sometimes very distress- 
ing. As the pains in the limbs are often taken for evidences 
of neuralgia or rheumatism, so these gastric and intestinal 
troubles are frequently regarded as indicating the existence 
of dyspepsia. I have had a number of patients under my 
charge who, with double vision, ptosis, incoordination, and 
the other symptoms of posterior spinal sclerosis, had been 
told that " it was all dyspepsia," because vomiting and gas- 
tric pain were prominent features of the disease. These 
symptoms are also due to the relations of the sympathetic 
nerves with the spinal cord, and are not present in cases 
where the lesion is low down in the lumbar region. 

When, however, this part of the cord is involved, there 
are very remarkable disorders of the genital system. These 
consist of frequent nocturnal emissions with or without erec- 
tions, or of an inordinate desire for sexual intercourse. A 
gentleman who consulted me a few weeks ago, and who was 



494 DISEASES OF THE SPINAL CORD. 

affected with the disease in question, informed me that he 
had several times had as many as eight seminal emissions in 
one night, and that his sexual desire was almost inextin- 
guishable. 

Paralysis of the bladder is a common circumstance, and 
the sphincter is not infrequently likewise affected. The 
bowels are usually obstinately constipated. 

The feeling of constriction around the body which is so 
common a symptom in acute myelitis, and which is met with 
in other organic affections of the cord, is rarely absent in 
cases of sclerosis of the posterior columns. 

Although the course of the disease in the great majority 
of cases is onward to a fatal termination, there are often 
periods of remission as in other spinal affections, and it rare- 
ly happens that the duration is not several years. A gen- 
tleman from Westchester County, in this State, has been af- 
fected for over twenty years, and still walks tolerably well. 
Another from Boston, sent to me by my friend Dr. Yan Bu- 
ren, had been subject to the disease for over twelve years. 
When I saw him he could not stand with his eyes shut, had 
the characteristic ataxic gait, was subject to genital and 
urinary difficulties, but yet was no worse than he had been 
six years previously. Another, from Pittsburg, has been in 
a stationary condition for several years ; and another, from 
Binghamton, in this State, remains about as he was three 
years ago. I could easily cite twenty others whom I occa- 
sionally see professionally, who hold their own, and who 
have been affected for from live to ten years. Romberg 
gives the average duration at from ten to fifteen, Jaccoud 
at from six to eight, and all authors agree that the course is 
slow. Of ninety-one patients affected with sclerosis of the 
posterior columns of the spinal cord who have been under 
my charge during the last six years, three only have as yet 
died, so far as I am aware. Of these, one had been affected 
seven years, one eight years, and one eight and a half 
years. There are several cases now under my charge in 



POSTERIOR SPINAL SCLEROSIS. 495 

which the affection has existed longer than either of these 
terms. 

The advance of the disease in the cord causes an aggra- 
vation of all the symptoms, and the appearance of others 
not previously noticed. The loss of motor power is now a 
prominent feature, the muscles become atrophied, bed-sores 
make their appearance, there is anasarca, and inflammations 
of the joints may occur. These latter are not common, but 
they are interesting as showing how disease of the cord may 
interfere with the due nutrition of the various parts of the 
body. 

Their connection with posterior spinal sclerosis was first 
pointed out by Charcot. 1 Previous to his observations, they 
had been noticed, but they were ascribed to an intercurrent 
rheumatism, and, many years before locomotor ataxia was 
recognized as an independent disease, the association of spi- 
nal disease with inflammation of the joints was pointed out 
by Prof. J. K. Mitchell, 3 of Philadelphia, and his son, Dr. S. 
Weir Mitchell, with Drs. Morehouse and Keen, 3 had also re- 
lated cases in which wounds of the spine had been followed 
by arthritis. Since Charcot's paper was published, Dr. Ben- 
jamin Bell * has cited cases of like affections coexisting with 
posterior spinal sclerosis. 

In the cases in question there is no fever, redness, or 
pain. The swelling is due to the accumulation of liquids 
in the synovial cavity, and this affection is the result of de- 
fective nutrition of the bony, cartilaginous, and soft parts 
connected with the joint. 

These accidents make their appearance usually in the 
interval between the occurrence of the shooting-pains so 

1 Sur quelques Arthropathies qui paraissent dependre de une lesion du 
Cerveau ou de la Moelle Epiniere, Archives de Physiologie, No. 1, January, 
1868, p. 161. 

8 American Journal of the Medical Sciences, vol. viii., 1831, p. 55. 

3 Gunshot Wounds and other Injuries of Nerves, Philadelphia, 1864. 

4 On Diseases of the Joints connected with Locomotor Ataxy, Medical Times 
and Gazette, October 31, 1868. 



496 DISEASES OF THE SPINAL CORD. 

characteristic of the first stage and the motor difficulties 
which mark the beginning of the second stage. 

Of the ninety-one cases of posterior spinal sclerosis which 
have come under my observation, in five only were there 
any difficulties of the joints. 

Death may take place either as the direct consequence 
of the lesion of the spine, or as the result of some intercur- 
rent affection such as pneumonia, dysentery, phthisis, or 
cystitis. 

Causes. — I have been very unsuccessful in my efforts to 
ascertain the cause in the greater number of persons, affected 
with sclerosis of the posterior columns of the spinal cord, 
who have been under my observation. The opinion is very 
prevalent that it is generally the result of excessive vene- 
real indulgence ; and, although this is undoubtedly some- 
times a cause, it certainly is not so common a one as is 
generally supposed. I have carefully inquired into the 
etiology of all the cases I have seen, and have only been 
able to assign inordinate sexual indulgence as the cause in 
seven. Injuries were apparently the cause in four cases, 
standing in a constrained position in three, the excessive 
use of alcoholic liquors in three, a syphilitic taint in three, 
undue mental exertion and anxiety in two, and in the re- 
mainder there was nothing that could be assigned as an ex- 
citing cause. So far as we know, it would appear that the 
etiology is identical with that of antero-lateral spinal scle- 
rosis. As regards the predisposing causes of age, sex, and 
hereditary influence, the similarity is equally well marked. 
Of the ninety-one cases observed by me, two only were in 
women. 

Diagnosis. — A consideration of the symptoms detailed in 
the foregoing pages will prevent posterior spinal sclerosis 
from being confounded with any other affection of the spi- 
nal cord. It may, however, be difficult at times to dis- 
criminate between it and lesions of the cerebellum, and the 
distinction has frequently not been made by very skilful 



POSTERIOR SPINAL SCLEROSIS. 497 

diagnosticians. At one time Duchenne held the view that 
locomotor ataxia was really the result of a lesion of the 
cerebellum, but he subsequently 1 retracted this opinion, 
and now believes that the spinal cord is the seat of the dis- 
order. 

In a recent memoir 2 1 have endeavored to point out the 
differences between cerebellar disease and the affection now 
called posterior cerebral sclerosis. In that essay I have 
said: "Derangement of locomotion certainly does result 
from injury or disease of the cerebellum. Experimental 
physiology, as well as pathology, proves this. Beyond a 
doubt the disorder is, however, clearly due to vertigo. 
There are, moreover, headache, vomiting, and eventually 
in some cases hemiplegia, generally of the opposite side to 
that of the cerebellar lesion, a fact at variance with Larrey's 
assertion. The gait of a person thus affected is exactly 
similar to that of a drunken man. As Carre says, the 
movements are not abrupt, jerking, and exaggerated, as 
they are in locomotor ataxia. They are more uncertain, 
and do not depend upon any defect of coordination, but 
upon weakness of the voluntary power. 

" When either of the peduncles of the cerebellum is ef- 
fected there is an irresistible impulse to go sideways, and 
sometimes gyratory movements are produced." 

The characteristic symptom of cerebellar lesion is ver- 
tigo ; and, although this is sometimes met with in posterior 
spinal sclerosis, it is not a prominent feature, and is rarely 
present at all except in the very earliest stage. 

In cerebellar lesions the cutaneous sensibility is unim- 
paired, whereas in posterior spinal sclerosis it is always di- 
minished. 

A patient with disease of the cerebellum can stand and 

1 Diagnostic differential des affections cerebelleuses et de l'ataxie locomo- 
trice progressive. Gazette Hebdomadaire, 1866. 

2 The Physiology and Pathology of the Cerebellum. Journal of Psycho- 
logical Medicine, April, 1869. 

32 



498 DISEASES OF THE SPINAL CORD. 

walk better with his eyes shut than with them open, for the 
vertigo is not in the former condition felt to the same ex- 
tent. The reverse is true of posterior spinal sclerosis. The 
history of the case will also serve as a good guide to the 
diagnosis. In the latter or even in the developed stage of 
posterior spinal sclerosis it would be difficult to mistake it 
for any other affection. 

Prognosis. — The prognosis is no more favorable than that 
of antero-lateral spinal sclerosis. A few cases are cured, 
more are relieved, but the great majority go on unchecked. 
Of the ninety-one cases upon which this chapter is based, 
five were cured. Of these, two were probably of syphilitic 
origin, but in the other three no such cause was at all prob- 
able. One of them was a woman. 

The cases in which amelioration has been produced are 
more numerous. In fact, it is not at all uncommon to suc- 
ceed in retarding the onward progress of the disease, and of 
thus prolonging the life of the patient. 

Morbid Anatomy. — Sclerosis of the posterior columns, as 
of the anterior, may be either diffused, multiple, or cortical. 
It may be restricted to the white substance of one or both 
posterior columns, or may also involve the gray matter. 
The posterior roots of the spinal nerves may also be impli- 
cated in the lesion. 

The situations of the lesions and their character were 
well known to Romberg * before the researches of Du- 
chenne, Charcot, and others. Thus he states that he was 
present at the post-mortem examination of the cord of a 
former patient. The organ was reduced one-third in diam- 
eter, and the atrophy was confined to the lower part of the 
posterior columns. The posterior nerve-roots were also in- 
volved, but the anterior columns were healthy. 

I have stated under the head of symptoms that posterior 
spinal sclerosis is often accompanied by " head-symptoms," 
and may be first manifested by an epileptic convulsion. So 

1 Op. cit., p. 399. 



POSTERIOR SPINAL SCLEROSIS. 499 

generally is it the case that there are cerebral difficulties 
that I hesitated for some time whether the disease should 
not be classed among those affecting the cerebro-spinal sys- 
tem. 

The lesions found in the brain never involve primarily 
the hemispheres. To be sure, it is sometimes the case that 
there are mental difficulties, but these come on toward the 
close, and are probably the result of defective nutrition. 

The cerebral lesions are in very intimate relation with 
the posterior spinal columns. They are therefore met with 
in the lower cerebellar peduncles, in the restiform bodies, 
and in the optic thalami, and consist of atrophy with de- 
generation. The optic nerve is apt to participate, and 
hence the principal ophthalmoscopic appearances to which 
attention has already been called. 

The other nerves which are often affected are the audi- 
tory, the third, and the sixth. 

Romberg x was well acquainted with the fact that the 
cerebral nerves are frequently atrophied in the disease un- 
der consideration. 

Although it is probable that the sympathetic is atrophied 
in some part of its extent, in many cases of posterior spinal 
sclerosis, the fact has not been demonstrated, except as re- 
gards one instance reported by Donnezan, in which a fila- 
ment from the superior cervical ganglion was found atro- 
phied. The ganglion itself was healthy. 

In the later stages of the affection the muscles may ex- 
hibit a condition of atrophy. In such cases their tissue will 
be found on microscopical examination to have undergone 
fatty degeneration and substitution to a greater or less ex- 
tent. 

Pathology. — The theory of posterior spinal sclerosis which 
is generally held is, that the lesion impairs a faculty by 
which the muscles are brought into harmonious action — a 
faculty of coordination. According to this view, the first 

1 Op. cit., p. 399. 



500 DISEASES OF THE SPINAL CORD. 

thing to be done was to locate this faculty in an organ, and 
Duchenne, with whom it originated, and who still holds 
it, adopting the ideas of Flourens and others, placed this 
faculty in the cerebellum, and therefore regarded what he 
designated progressive locomotor ataxia as a disease of the 
cerebellum. 1 Thus he says : 

" In conclusion, regarding the order of appearance, and 
the habitual progress of the symptoms which mark the three 
periods of progressive locomotor ataxia, we find that the 
central morbid action which produces the phenomena symp- 
tomatic of this disease begins in general in the motor nerves 
of the eye, and in the tubercular quadrigemina, extending 
thence to the superior and inferior cerebellar peduncles and 
finally to the cerebellum." 

As already stated, Duchenne has since abandoned this 
view of the location, and now assigns its seat to the poste- 
rior columns of the cord, but, in order to make the morbid 
anatomy agree with the theory of the disease which he holds, 
he places his faculty of coordination in the cord. But, al- 
though it has been established by numerous post-mortem 
examinations that the cerebellum is not the seat of lesion 
in cases of locomotor ataxia, and although the differential 
diagnosis between diseases of the cerebellum and posterior 
spinal sclerosis has been very clearly made out, there are 
some who still hold the view that, although the cerebellum 
shows no traces of disease, and that, although the posterior 
columns of the spinal cord may be in a state of sclerosis, the 
symptoms are the result of an interruption to the passage, 
from the cerebellum through the posterior columns to the 
spinal nerves, of that force which coordinates the muscles 
into harmonious action. In the memoir to which reference 
has already been made, I have entered at length into the 
consideration of the question of the location of a coordinat- 
ing faculty in the cerebellum, and have, I think, adduced 
sufficient facts and arguments to show that coordination is 
1 De l'Electrisation localisee, deuxieme edition, Paris, 1861, p. 611. 



POSTERIOR SPINAL SCLEROSIS. 501 

not one of its functions. Without going into a full account 
of the subject, a synopsis of the conclusions arrived at will 
probably not be deemed out of place : 

1. The consequences of removal of the cerebellum, if 
the animal survives the immediate effects of the injury, 
are not enduring. This conclusion is supported by experi- 
ments by Flourens, 1 Harting, 9 Wagner, 3 Dalton, 4 myself, 5 
and others. The physiological inference, of course, is, that, 
if the faculty of coordination resided in the cerebellum, it 
ought to be permanently removed with the ablation of the 
organ. 

2. The entire removal of the cerebellum from some ani- 
mals does not apparently interfere in the slightest degree 
even for a moment with the regularity and order of their 
movements. I have performed a number of experiments 
with reference to this point, on different classes of animals. 
They prove very clearly that the cerebellum is not the gen- 
erator of coordinating power in all animals that have it : 
a fact in comparative physiology which is fatal to the hy- 
pothesis that this is its function in man. 

3. The disorder of movements which results in birds and 
mammals immediately after injury of the cerebellum is not 
due to any loss of coordinating power, but is the result of 
vertigo. 

If the cerebellum be removed from a pigeon it exhibits 
disorder in its movements, but a careful examination of the 
phenomena exhibited, shows that it is suffering from a 
vertiginous sensation. Even when placed upon its breast 

1 Recherches experimentales sur les proprieties et les fonctions du systeme 
nerveux, Paris, 1842. 

8 Experimenta quaedam de affectibus laesionum in partibus encephale, 1826. 

3 Nachrichten von der Universitat und der Konigl Gesellsehaft der Wissen- 
schaften zu Gottengen; also Journal de la physiologie de l'homme et des ani- 
maux, Avril, 1861. 

4 American Journal Medical Sciences, January, 1861, p. 83 ; also Treatise 
on Human Physiology, 4th edition, 186V, p. 416. 

5 Op. cit., p. 24. 



502 DISEASES OF THE SPINAL COED. 

and allowed to remain at rest, there is a trembling and 
swaying of the body, such as is produced by alcoholic intoxi- 
cation. Exactly such symptoms can be caused by giving 
pigeons bread soaked in alcohol. 

4. The phenomena of cerebellar disease or injury, as ex- 
hibited in man, are not such as show any derangement of the 
coordinating power. 

Many cases are on record which support this proposition. 
Andral 1 states that, of ninety-three cases of cerebellar dis- 
ease which he has studied, only one appeared to support the 
theory which locates the coordinating power in the cere- 
bellum, i 

Many special instances might be brought forward, and 
several have occurred in my own practice. The case of 
Alexandrine Labrosse, reported by Combette, 2 is, however, 
worth referring to more specifically. His paper is entitled 
" Case of a young girl who died in her eleventh year, in 
whom there was complete absence of the cerebellum, of the 
posterior peduncles and of the annular protuberance." 
Magendie examined the brain after her death, and satisfied 
himself that the defect was congenital. As M. Combette 
remarks in regard to this case, Alexandrine Labrosse had 
been able to walk for several years, but always in an uncer- 
tain manner. Gradually her legs lost their strength, and 
she became paraplegic. She preserved the use of her upper 
extremities to the last. It is very evident, therefore, that 
the weakness of her legs was due to paralysis, for, had it 
been the result of incoordination, the arms must necessarily 
have participated. 

For these reasons, I think, it cannot be considered with 
any degree of probability that the cerebellum has any thing 
whatever to do with the symptoms manifested in sclerosis 
of the posterior columns of the cord. Neither is it, in my 

1 Clinique Medicale, seconde edition, tome v., p. 735. 

2 Journal de Physiologie experimental et pathologique, par F. Magendie, 
tome xi., Paris, 1831, p. 27. 



POSTERIOR SPINAL SCLEROSIS. 503 

opinion, necessary to assume the existence of an organ 
whose office it is to exercise a coordinating power. 

Other authors have ascribed the incoordination which is 
so prominent a phenomenon of posterior spinal sclerosis to 
the loss of what they call the muscular sense. 

Sir Charles Bell 1 has argued strongly in support of the 
existence of such a sense. He enunciates his theory in the 
following sentence : 

" Between the brain and the muscles there is a circle of 
nerves ; one nerve conveys the influence from the brain to 
the muscle, another gives the sense of the condition of the 
muscle to the brain." 

It is by this connection that we are enabled, according 
to Sir Charles Bell and other physiologists, to form an idea 
of the state of contraction of a muscle, and to lessen or in- 
crease the contraction as may be necessary. According to 
some writers, in posterior spinal sclerosis the patient loses 
this muscular sense, or is unable to exert it, for the reason 
that the spinal columns through which the perception 
reaches the brain are, by disease, rendered incapable of 
transmitting it. 

In my opinion — and I shall endeavor to support it pres- 
ently — there is no such a perception as that referred to, and 
its existence is certainly not established by the case reported 
by Dr. Ley to Sir Charles Bell, and which is incorrectly 
quoted by Trousseau ; for it proves nothing more than that 
defective sensibility existed, and that the sense of sight had 
to be used in order to obtain a correct idea of what the in- 
sensible muscles were doing. 

A lady having been recently delivered, and having suf- 
fered severe haemorrhage, was seized soon afterward with 
headache and numbness. Dr. Ley was called to see her. 

"I found her," he says, "laboring under severe head- 

1 On the Nervous Circle which connects the Voluntary Muscles with the 
Brain. Philosophical Transactions. Also, The Nervous System of the Human 
Body. London, 1830, p. 225. 



504 DISEASES OF THE SPINAL CORD. 

ache, not confined to, but infinitely more violent upon one 
side than the other, and occupying the region of the tem- 
poral and occipital bones above the mastoid process, and 
attended with considerable pulsation. 

" Upon one side of the body there was such defective 
sensibility, without, however, corresponding diminution of 
power in the muscles of volition, that she could hold her 
child in the arm of that side so long as her attention was 
directed to it ; but, if surrounding objects withdrew her 
from the notice of the state of her arm, the flexors gradu- 
ally relaxed, and the child was in hazard of falling. The 
breast, too, upon that side, partook of the insensibility, 
although the secretion of milk was as copious as in the other. 
She could see the child sucking and swallowing, but she had 
no consciousness from feeling that the child was so occupied. 
Turgescence of that breast produced no suffering, and she 
was unconscious of what is termed the draught on that side, 
although that sensation was strongly marked in the other 
breast. 

"Upon the opposite side of the body there was defective 
power of motion, without, however, any diminution of sen- 
sibility. The arm was incapable of supporting the child, 
the hand was powerless in its grip, and the leg was moved 
with difficulty and with the ordinary rotatory movement of 
a paralytic patient, but the power of sensation was so far 
from being impaired that she constantly complained of an 
uncomfortable sense of heat, a painful tingling, and more 
than the usual degree of uneasiness from pressure or other 
modes of slight mechanical violence." 

After a few months she died ; having, in the mean time, 
received no improvement from the active treatment em- 
ployed, and having also become pregnant again. On post- 
mortem examination there were found evidences of chronic 
inflammation of the membranes of the brain. The cord 
was not examined. Certainly this case presents nothing 
which may not be met with in any patient who has anass- 



POSTERIOR SPINAL SCLEROSIS. 505 

thesia on one side and paralysis of motion on the other. I 
have observed a number of similar cases, and they neither 
prove the existence of a muscular sense, nor do they have 
any special bearing on posterior spinal sclerosis beyond the 
fact that they exhibit deficient sensibility. 

But, before proceeding to the further discussion of this 
subject, clear ideas should be entertained relative to the 
anatomy and physiology of the spinal cord. The researches 
of Dr. J. Lockkart Clarke have given us very exact infor- 
mation on these points, and I shall therefore quote from him 
in full. 1 

As Dr. Clarke states, before he began his researches on 
the structure of the spinal cord, it was universally taught, 
both in England and abroad, that the posterior roots of the 
spinal nerves were attached exclusively to the lateral col- 
umns of the cord ; whereas he showed, what is now univer- 
sally admitted, that they are attached immediately to the 
posterior columns, and not at all to the lateral. The im- 
portance of this fact in both a physiological and pathological 
point of view, and especially in its relation to posterior spi- 
nal sclerosis, will presently appear. 

In Fig. 2i, which represents a transverse section of the 
left lateral half of the lumbar enlargement of the cord, the 
posterior nerve-roots (I) are seen to enter through nearly the 
entire breadth of the posterior column (a) ; and in Fig. 25, 
which represents a longitudinal section of the cervical en- 
largement of the cord, we see the course of the roots of four 
consecutive nerves (P, P, P, P) within the cord. These 
roots are of three kinds :' The first kind (a, a, a, a) enter 
the cord transversely, and pursue a very remarkable course. 
Each bundle, after traversing the longitudinal fibres of the 
posterior column (P C) in a compact form, and at a right 
angle, continues in the same direction to a considerable but 

1 See Dr. Clarke's paper on "Locomotor Ataxy," in British Medical Journal, 
September 25, 1869, p. 344, from which I take this account and the accom- 
panying woodcuts. 



506 



DISEASES OF THE SPINAL CORD. 
Fig. 24. 



^m 




variable depth within the gray substance (G), dilating and 
again contracting, so as to assume a fusiform appearance. 




It there bends round upon itself, at a right or more obtuse 
angle, and, running for a considerable distance in a longitu- 



POSTERIOR SPINAL SCLEROSIS. 507 

dinal direction down the middle of the cord, sends forward, 
at short intervals, into the anterior gray substance, a series 
of fibres, some of which mingle with those of the anterior 
roots (A), while others enter the anterior white column, as 
at AC, AC, in which they run longitudinally, both upward 
and downward. 

The second kind of posterior roots (b, b, b) also traverse 
the posterior column transversely, but sometimes a little 
obliquely from without inward. Their component fibres 
are finer than those of the other bundles, measuring about 
the 7 \ th of an inch in diameter. Some of these fibres 
cross over transversely to the gray substance of the opposite 
side through the posterior commissure behind the canal. 
Others extend into the posterior and lateral white columns 
of the same side, while the rest may be traced deeply into 
the anterior gray substance (G, Fig. 23), where they diverge 
in different directions, and are ultimately lost to view. 

The bundles forming the third kind of posterior roots 
(<?, c, <?, Fig. 23) enter the end obliquely. A few of their 
fibres proceed near the surface of the posterior column both 
upward and downward, and pass out again with roots above 
and below them. The rest cross the posterior column ob- 
liquely and chiefly upward, a small number only running 
downward. Interlacing at the same time with each other 
and with the roots already described, these fibres diverge, 
and for the most part reach the gray substance at points 
successively more distant from their entrance into the cord 
in proportion to the obliquity of their course, the most di- 
vergent and superficial taking a longitudinal course at least 
for some distance, with the fibres of the posterior column, 
among which they are lost. From these investigations 
(Philosophical Transactions, 1853), Dr. Clarke inferred that 
the posterior white columns of the cord cannot be the only 
channels for the transmission of sensory impressions, an in- 
ference which was verified two years later by the experi- 
ments of Brown-Sequard (Gazette Medicale, 1855). 



508 DISEASES OF THE SPINAL CORD. 

Such being the anatomical connection of the posterior 
nerve-roots with the posterior columns of the cord, it is evi- 
dent that scarcely any part of the length of those columns 
can be damaged either by injury or disease without involv- 
ing destruction of a corresponding number of nerve-roots ; 
and, since reflex action of the cord requires that impressions 
be conveyed by nerve-roots to the gray substance, the dimi- 
nution of reflex action in cases of injury to the posterior col- 
umns is thus readily explained. 

Dr. Clarke, in the anatomy and physiology of the pos- 
terior nerve-roots and their relations to the cord, which he 
has thus so satisfactorily elucidated, presents a theory of the 
phenomena of incoordination met with in posterior spinal 
sclerosis, to which I will allude more specifically directly. 
In the mean time a few words in reference to the " muscular 
sense " are necessary to the understanding of the whole 
subject. 

Landry l declares that, whenever a muscle is caused to 
contract, the brain perceives the seat and the extent of the 
contraction. I am very sure that no sensation starts from 
the muscle which can give the brain any idea on the sub- 
ject. As Trousseau a remarks : 

" An important distinction must be drawn between the 
consciousness of a movement which has been executed, and 
the consciousness of the muscular contraction which per- 
forms the movement. When after shutting our eyes we ex- 
ecute without effort a pretty extensive movement, we are 
unable, even on paying the strictest attention, to feel the 
contraction of our muscles, although we may feel the move- 
ment communicated to the lever by the contracted muscles. 
This fact is so true, that, when we ask an intelligent person, 
who knows nothing of anatomy and physiology, which is 
the seat of the movements through which the fingers are 
flexed or extended, he immediately points to the hand, and 

1 Memoire sur la paralysie du sentiment d'activite inusculaire, Paris, 1855. 
8 Op. cat., p. 159. 



POSTERIOR SPINAL SCLEROSIS. 509 

never to the forearm. It is only when the muscular effect 
is considerable and kept up for a long time, that it is per- 
ceived where the contraction really occurs. Normally, then, 
we have no consciousness of muscular activity, but merely 
the consciousness of the movement itself, which is a perfect 
ly different thing." 

In a very thorough essay on the subject, Dr. Bastian * has 
discussed the whole subject of the " muscular sense." He 
denies — and I think with good reason — the existence of any 
such special sense. In his opinion, there is no consciousness 
of the state of muscular contraction, and that the estimations 
by which we regulate the extent to which it is necessary, for 
instance, to contract the muscles of the upper extremity to 
sustain a certain weight in the hand, are " inferences based 
upon previous sensory impressions of the passive kind, upon 
impressions emanating from the skin, from the joints, and 
from the muscles themselves, so that in my opinion there 
are no conscious impressions derivable through the ' muscu- 
lar sense.' " This, as I think, is not to be considered as an 
appanage of the intellect, but rather as an unconscious or- 
ganic guide in the performance of voluntary movements. 
Why, it may be asked, do I not, as Trousseau has already 
done, deny its existence altogether ? And to this I should 
reply by saying : " Although there is no evidence to lead us 
to believe that we derive any conscious impressions through 
the intervention of this so-called ' muscular sense,' there is 
evidence to show that the brain is assisted in the execution 
of voluntary movements by guiding impressions of some 
kind, which, while they differ from the impressions produ- 
cible by means of the ordinary cutaneous and deep sensibility, 
may differ still further from these, owing to the fact of their 
not being revealed in consciousness at all." 

This impresses me as being a very philosophical view of 
this rather difficult question, and it is in part sufficient to ex- 

1 Remarks on the " Muscular Sense " and on the Physiology of Thinking. 
British Medical Journal, May 1, 1869, and subsequent numbers. 



510 DISEASES OF THE SPINAL CORD. 

plain the incoordination existing in cases of posterior spinal 
sclerosis ; but, for the full understanding of the subject, it 
appears to me we must bring forward another fact in the 
physiology of the spinal cord which has not hitherto, so far 
as I know, been made applicable. The spinal cord serves 
two distinct purposes in the economy. It transmits nervous 
force to and from the brain, and it is a centre which gener- 
ates nervous force. Referring now to the anatomical de- 
tails given by Dr. Lockhart Clarke, we find that the pos- 
terior nerve-roots not only reach the white substance of the 
posterior and antero-lateral columns, but that they are in 
intimate relation with the gray matter. Now, the white 
substance simply serves for the transmission of nervous force, 
the gray elaborates it. Hence a great many of the muscular 
actions which we perform are done through the agency of 
this gray matter of the cord, and are without the interven- 
tion of the brain, and the brain can only be brought to bear 
upon them through the agency of the white substance. The 
states of muscular contraction are, therefore, in all proba- 
bility, perceived by the gray substance of the cord, and, as 
the brain has no consciousness of the perceptions of the cord, 
we are not made aware of the states of muscular contraction. 
The muscular sense, therefore, does not exist, at least in the 
same manner as do the other senses. 

In sclerosis of the posterior columns of the spinal cord 
the lesion generally involves the posterior nerve-roots, the 
posterior white substance, and the posterior cornua of gray 
substance. Hence the cord loses both in the ability to trans- 
mit and to generate nervous force. Those unconscious acts 
of muscular coordination which are regulated by the gray 
substance of the spinal cord can no longer be perfectly ac- 
complished, and the brain is brought to assist in the deter- 
mination through the sense of sight. The patient cannot 
stand well with his eyes shut, or walk in the dark, or deter- 
mine differences of weight, because he is relying altogether 
on the perceptive faculty of the spinal cord, and this organ 



POSTERIOR SPINAL SCLEROSIS. 511 

is not in a condition to perform its work with precision ; 
and his movements and muscular contractions are rendered 
still more uncertain from the fact that the cutaneous sensi- 
bility is diminished. 

In the normal condition we frequently — in determining 
weights, for instance — are greatly assisted by the sense of 
sight, and there is nothing surprising in the fact that, in a 
disease like posterior spinal sclerosis, the spinal cord should 
be unable to perceive states of muscular contraction without 
the assistance of the brain. And, as the conducting power 
of the cord is also lessened, the brain cannot act with its full 
power ; and, therefore, even with all the assistance to be de- 
rived from the chief generator of nervous force in the body, 
the patient's muscles are not so well coordinated as in health. 

Dr. Lockhart Clarke, in the memoir already cited, ex- 
plains the incoordination upon another principle, which, 
although, as I think, not sufficient to account for the phe- 
nomenon, may, and probably does, exercise some influence. 
His view is, that there is a physiological state of the muscles 
dependent on reflex action, that is absolutely essential to the 
proper coordination of voluntary movements, and that is, 
their tonicity, or that moderate but constant state of con- 
traction which keeps the antagonist muscles, or those that 
are variously opposed to each other, in equilibrium or static 
tension. In the performance of voluntary movements a 
constantly-varying number of muscles, each of which differs 
more or less in force and in the particular direction which it 
gives to the limb or part, are associated together in action 
in an endless variety of ways. Each of the muscles that 
compose these varying groups must contract either simul- 
taneously or successively to a certain particular extent, with 
a certain degree of force, and with a certain degree of rapid- 
ity, in relation to the actions of the others, according to the 
resultant direction desired in the voluntary effort ; and this 
endless variety of ways, in which a constantly- varying num- 
bei of muscles are balanced against each other in contrac- 



512 DISEASES OF THE SPINAL CORD. 

tion for the performance of constantly-varying and compli- 
cated voluntary movements, affords the most exquisite and 
beautiful example of what, in physical science, is termed 
the composition of forces. In this balancing of muscular 
force we have to learn, by experience, and to remember the 
exact voluntary effort required to contract each muscle to 
its proper extent, with its proper force, and with its proper 
degree of rapidity, in relation to the action of the others 
that complete the group employed. Now, it is evident that 
if some of the muscles of the group employed have lost their 
normal tension or tone, they will not properly respond to 
the intentions of the voluntary stimulus, and will fail to 
perform their proper part in balancing the effects of the 
other muscles of the group that retain their tension, in the 
execution of any given movement. In proportion, there- 
fore, to the exact amount of tension lost by any muscle or 
muscles of the group, and the number of muscles that have 
lost that tension, there must necessarily be a proportionate 
amount of disorderly movement of incoordination. But it 
appears to be satisfactorily proved, by the experiments of 
Brondigeest, Rosenthal, and others, that this constant ten- 
sion or tone of the voluntary muscles is due to a constant 
reflex action of the cerebro-spinal centres, and is immedi- 
ately dependent on impressions conveyed from the muscles 
to those centres by the posterior roots of the nerves. Now, 
Dr. Clarke has shown how these posterior spinal roots are 
spread out through the posterior columns of the cord ; how 
impossible it is for these columns to be destroyed to any 
great extent without involving destruction of the nerve- 
roots ; and how, consequently, the columns are so destroyed 
in locomotor ataxia. But, except in the very last stage of 
this malady, all the posterior roots are not injured by disin- 
tegration, and some of them are still competent to carry 
impressions to the gray substance of the cord ; so that some 
of the muscles retain their tone, while others lose it to a 
greater or less extent. 



POSTERIOR SPINAL SCLEROSIS. 513 

This is Dr. Clarke's explanation of the peculiar feature 
of posterior spinal sclerosis, in almost his own words. That 
it is ingenious and plausible, all physiologists and patholo- 
gists will admit. 

Treatment. — A great many medicines have been em- 
ployed in the treatment of sclerosis of the posterior columns 
of the spinal cord, but few have been productive of any 
material benefit. Leaving out of mention those which my 
experience has taught me are inefficacious, I will specifically 
refer only to those which I have seen produce some amelio- 
ration of the symptoms. 

As in the corresponding affection of the antero-lateral 
columns, ergot in large doses is often beneficial in the early 
stages of the disease, and the bromide of potassium may be 
combined with it in doses of from thirty grains to a drachm 
three times a day. Cod-liver oil is always advantageous, 
and the primary galvanic current applied as recommended 
for antero-lateral sclerosis is a main feature of the treat- 
ment. 

I ordinarily begin the treatment of every case of pos- 
terior spinal sclerosis by these means if the disease has not 
yet passed beyond the first stage — that which is character 
ized by the presence of the shooting electric pains previous- 
ly described — employing at the same time measures directed 
to the relief of particular difficulties. Thus, for gastric de- 
rangements, bismuth will often prove of service, or the 
constant galvanic current may be passed through the pneu- 
mogastric nerve, the positive pole being placed over the 
nerve in the neck, and the negative rubbed over the epigas- 
tric region, or, what is usually still more efficacious, Bou- 
dault's pepsin may be given in doses of fifteen or twenty 
grains with each meal. I have frequently had the most 
satisfactory results from this agent when all others have 
failed. 

The pains in the back and around the abdominal or 
thoracic regions are best combated with codeine in doses of 
33 



514 DISEASES OF THE SPINAL CORD. 

from half a grain to one or two grains, according to circum- 
stances. 

If the case comes under observation when the motorial 
difficulties are well marked, or, if, after having used it for a 
month, no decidedly beneficial effect follows the treatment 
just specified, I omit the ergot, and use instead, the nitrate 
of silver in doses of the quarter of a grain three times a day. 
This remedy has apparently proved serviceable in several 
cases which were well advanced, but I am not able to speak 
definitely on the subject, for the reason that with it bromide 
of potassium, and especially galvanism, were used. Two 
cases were cured by the combined remedies — one of them 
was that of a distinguished journalist, who, in the first place, 
was treated with ergot, and subsequently, when this medi- 
cine appeared to be of no further effect, with the nitrate of 
silver. At the present time this gentleman is well, free 
from pains, able to coordinate, and with no symptom of the 
affection remaining. The disease was first manifested by an 
epileptic paroxysm, and soon afterward ocular troubles made 
their appearance. He was under treatment for about four 
months. The other case was that of a lady of this city. 
The disease, in her, began with pain in the back, and elec- 
tric pains in the lower extremities. Ptosis, dilatation of the 
right pupil, and diplopia followed, and then gradual loss of 
sensibility in the soles of the feet, and difficulty in coordi- 
nating the muscles of the legs. The disease had lasted two 
years and a half when the patient came under my charge. 
She was treated with the nitrate of silver and the other 
remedies mentioned for nearly a year, and throughout the 
whole period' gradually improved till her recovery was com- 
plete. The nitrate of silver was suspended for a week after 
each month of its administration. 

In a third case ergot and nitrate of silver were given to- 
gether without the bromide of potassium. This case was 
that of a gentleman, a merchant of this city, residing in 
Bridgeport, Connecticut. He had had ocular troubles, and 



POSTERIOR SPINAL SCLEROSIS. 515 

was suffering from pains, incoordination, plantar anaesthesia, 
paralysis of the bladder, and swelling of the right knee, 
when he came nnder my charge, being sent to me by my 
friend Dr. Hubbard, of Bridgeport. The disease had then 
lasted only a few months. With the medicines, the constant 
galvanic current to the spine and spinal nerves was em- 
ployed. He was entirely cured in less than three months. 
In all cases inquiry should be made with reference to the 
existence of a syphilitic taint. If affirmative results follow 
the investigation, the iodide of potassium should be admin- 
istered in gradually-increasing doses as recommended for 
acute spinal meningitis, or in combination with corrosive 
sublimate, according to the formula given on page 322, 
recollecting that galvanism is likewise to be used, and such 
other treatment as the special symptoms may seem to re- 
quire. Two cases were cured by this treatment ; one of 
them was that of a gentleman from the West — a fully-de- 
veloped case — who had been treated by my friend Dr. 
Bumstead for other syphilitic troubles, and who sent him 
to me for his spinal difficulty. The incoordination, plantar 
anaesthesia, pain in the lumbar region, and the electric 
pains, were all present, together with slight diplopia. He 
was under treatment for about ten months. I met him a 
few weeks since in a railway-car, the picture of health, and, 
as he told me, perfectly well. 

The other case occurred in the person of a gentleman of 
this city, and was similar in general features to the preced- 
ing. A cure was obtained, after like medication, in six 
months. 

. In several cases I have obtained ameliorations by the 
use of phosphoric acid, phosphorus, and chloride of barium. 
My experience with the latter medicine is not as yet suffi- 
cient to enable me to say that it has effected a cure, but the 
therapeutical promise is good. I have administered it in 
eight cases with decided benefit. Five of these are still un- 
der treatment with it. If the vesical sphincter be paralyzed, 



516 DISEASES OF THE SPINAL CORD. 

belladonna may be used with advantage. Hydro-therapeu- 
tics in all forms, counter-irritation of all kinds, and fara- 
disation, have never, according to my experience, been of 
the slightest benefit, except as regards the use of the latter 
to the affected muscles. The ether-spray recommended by 
Jaccoud has been entirely inefficacious in my hands, and 
the same may be said of all plasters and embrocations. 

. One auxiliary means of treatment I have lately em- 
ployed with advantage, and that is, keeping the patient as 
much as possible from using the groups of muscles which 
have lost their coordinating power, and requiring him, when 
he walks, to employ crutches to assist him. By systemati- 
cally carrying out this plan the nervous force of the patient 
is not wasted, and a diseased organ, such as is his spinal 
cord, is not overtasked. 

Without making a separate chapter for the subject, it 
may be well to mention here the fact that chronic myelitis 
may affect a lateral half of the cord embracing in the lesion 
one antero-lateral and one posterior column, or any other 
combination of columns. Several such have come under 
my observation, and an interesting case of lesion of an an- 
tero-lateral and posterior column of one side is reported in a 
clinical lecture on Spinal Paralysis, 1 delivered by me at the 
Belle vue Hospital Medical College. The patient is still at 
the New York State Hospital for Diseases of the Nervous 
System, and is steadily improving. 

1 Journal op Psychological Medicine, January, 1871. 



CHAPTEE IX. 

TUMORS OF THE SPINAL CORD. 

Following the example of Jaccoud, I shall consider 
under one head, tumors of the cord, of the membranes, and 
those which, growing from the interior surfaces of the ver- 
tebrae, may compress the cord, and thus interfere with its 
functions by deranging its structure. In the present state 
of our knowledge, we have no sufficiently exact data by 
which to discriminate between these several growths. 

Symptoms. — The phenomena which result from intra- 
spinal tumors, like those due to congestion, are of two cate- 
gories, resulting as they do either from irritation or com- 
pression. Under the first head are embraced pain in the 
back, in the limbs, and in the viscera, if the posterior col- 
umns are mainly the seat of the lesion or subjected to the 
pressure of a vertebral tumor, and twitchings of the muscles, 
and contractions of the limbs, if the antero-lateral columns 
are principally involved. When both sets of columns — as is 
generally the case — are affected, the troubles of sensibility 
and of motility are both present. 

If the tumor is situated in the cervical or upper dorsal 
region, there is generally tonic contraction of the muscles 
of the neck, by which the head is thrown backward, caus- 
ing the patient to present the appearance of a person affect- 
ed with the opisthotonos of tetanuos. There are in such a 
case usually ocular troubles, such as those previously men- 
tioned, and more or less gastric derangement. The symp- 
toms, so far as the limbs and viscera are concerned, vary 



518 DISEASES OF THE SPINAL CORD. 

in their extent according to the situation of the morbid 
growth. 

The symptoms of compression are anaesthesia and motor 
paralysis. These may or may not be accompanied with 
muscular atrophy. Keflex excitability and electro-muscular 
contractility are generally at first increased, or at least not 
lessened, but, as the pressure increases and the structure of 
the cord becomes more disorganized, they are lessened. 

Many cases, of what may with Drs. Charcot and Brown- 
Sequard be called hemi-paraplegia, are due to spinal tumors. 
It often happens that these are small and compress a lateral 
half of the cord, leaving the other affected only by the trans- 
mitted pressure. A very remarkable case has been report- 
ed by Charcot, 1 in which the left inferior extremity was 
completely paralyzed, while the right was simply weak 
without having lost the power of contraction in any of its 
muscles. On the other hand, sensibility was greatly les- 
sened in the right limb, while it was exalted in the left. 
There was paralysis of the bladder, but no atrophy of either 
limb. Finally, anasarca and bed-sores appeared, and the 
patient gradually sank. On post-mortem examination, a 
tumor was found growing from the dura mater on the ante- 
rior face of the cord and compressing its left lateral half. 
The accompanying woodcuts (Figs. 26 and 27), reduced 
from Charcot's lithographic representations, show the situ- 
ation and relations of this tumor. Fig. 26 shows the growth 
in situ, and Fig. 27 the parts as they appeared when the 
tumor was pushed aside so as to allow the cavity to be seen 
in which it was lodged. 8 

Eecollecting the facts that the fibres of the anterior or 
motor columns of the cord decussate at the medulla oblon- 

1 Archives de Physiologie, No. 2, p. 291. 

2 This case is quoted at length by Dr. Brown-Sequard in the Lancet of Sep- 
tember 25, 1869, p. 429. In previous and subsequent numbers of this journal 
Brown-Sequard has contributed much valuable information on the subject of 
hemi-paraplegia. 



TUMORS OF THE SPINAL CORD. 



519 



gata, while those of the posterior or sensory columns cross 
over soon after they enter the cord from the posterior roots 
of the spinal nerves, we can understand why, when the pa- 
ralysis of motion is confined to one side, or is greater on that 
side, that the lesion is on the corresponding side of the cord, 



i 



Fig. 27. 




and that this loss of motility should be accompanied with 
anaesthesia of the opposite side of the body. 

Under the name of painful paraplegia (paraplegie dou- 
loureuse), Cruveilhier referred to a form of spinal disease 
which has been subsequently described more fully by Char- 
cot. This latter author has observed six cases, in all of which 



520 DISEASES OF THE SPINAL CORD. 

there was cancer of the mammary gland. In three of these 
he had the opportunity of making post-mortem examinations, 
and discovered carcinoma of a lumbar vertebra in each, to 
which the irritation and compression of the cord were due. 
According to him, " the skin, especially during the parox- 
ysms of pain, is often very sensitive to the touch. At the 
same time walking becomes troublesome, and later the pa- 
tient cannot walk without help ; finally, muscular atrophy 
ensues, and the patient loses the power to stand." 

Simon, 1 from whom I quote these details, under the head 
of " paraplegia dolorosa," describes a case which came 
under his own observation, in which, during life, symptoms 
similar to those mentioned by Charcot, were noticed, and 
in which, after death, a cancerous tumor was found growing 
from the first lumbar vertebra and compressing the posterior 
columns of the cord. Other lesions were present, in the 
posterior columns both above and below the tumor; they 
were apparently of the nature of sclerosis. Similar cases 
have been described by other authors. 

Although it is rendered certain that cancerous tumors 
of the vertebrae may give rise to paraplegia characterized by 
great pain, it must be borne in mind that these symptoms 
are not a necessary accompaniment of the lesion, and that 
they are met with in other affections of the cord. 

Causes. — Nothing is known relative to the etiology of 
intra-spinal tumors beyond the fact that they may result 
from the syphilitic, scrofulous, and cancerous diatheses. 

Diagnosis. — There are no certain marks by which we can 
determine with any great degree of certainty that a tumor 
is compressing the spinal cord. We may suspect such to be 
the case when the motor paralysis is more marked on one 
side of the body than the other, and the anaesthesia exists to 
a greater extent on the opposite side. The existence of 

1 Berliner Klinische Wochenschrift, Hefte 35 and 36, 1870 ; also Journal of 
Psychological Medicine, January, 1871, p. 125, translation and abstract by Dr. 
D. F. Lincoln. 



TUMORS OF THE SPINAL CORD. 521 

either syphilis, scrofula, or cancer, in connection with spinal 
difficulties not clearly referable to some other disease, may 
likewise excite the suspicion that a tumor exists. 

Prognosis. — This is always unfavorable. It is less so 
when a syphilitic origin can be made out. JSTo others re- 
cover. 

Morbid Anatomy and Pathology. — The most common intra- 
spinal morbid growths are those which are developed from 
the vertebrse, and they include many syphilitic, scrofulous, 
and cancerous tumors. They originate either from the 
bones or from the periosteum. Formations resulting from 
either of these diatheses may also grow from the meninges 
or the substance of the cord. 

Parasitic tumors due to either the echinococcus or the 
cysticercus may also be developed within the spinal canal. 
Their usual seat is in the membranes ; and, according to 
Ollivier, 1 the echinococcus is found in the spinal cavity of 
women only. 

Aneurismal tumors occasionally form in the intra-spinal 
arteries, and may compress the cord. Aneurisms of the 
thoracic or abdominal aorta may, by pressure, cause absorp- 
tion of the vertebrse, and may thus eventually subject the 
cord to their influence. 

Treatment. — The attempt should always be made, when- 
ever the existence of a tumor of the spinal cord is suspected, 
to effect its removal by anti-syphilitic treatment, with iodide 
of potassium and mercury. The following case will show 
the advantages of following this course : 

In the summer of 1869 I was requested to visit a gentle- 
man who I was informed was paraplegic and subject to 
paroxysms of great suffering. On making my examination 
I found his limbs contracted, his reflex excitability aug- 
mented, and motor paralysis and anaesthesia of both lower 
extremities. There were intense pain in the lower dorsal 
region, and violent spasms of the sphincter vesicae, alternat- 

1 Traite des Maladies de la Moelle Epiniere, Paris, 1837, t. ii., p. 549. 



522 DISEASES OF THE SPINAL CORD. 

ing with paralysis of it and the bladder. There were also 
paroxysms of severe pain in the head, and occasional attacks 
of delirium. He denied any syphilitic infection, but, on ex- 
amining his head with my hands, I found a gummy tumor 
of the scalp over the right occipital region. Further in- 
quiry and examination revealed the existence of a similar 
tumor over the left radius. I inferred that there might be 
one or more like growths within the spinal canal, and I 
administered the iodide of potassium in gradually-increasing 
doses, with the bichloride of mercury in doses of the six- 
teenth of a grain three times a day. In less than two 
months every symptom of disease, except a general weak- 
ness, had disappeared. The tumor of the scalp went during 
the first month ; that of the arm a week later. The iodide 
of potassium was carried up to fifty grains three times a 
day. This patient continues in good health up to the pres- 
ent time. Even if there was not sufficient reason to diag- 
nosticate the existence of an intra-spinal syphilitic tumor, 
the success of the treatment can scarcely leave a doubt on 
the subject. 



CHAPTEK X. 

SECONDARY DEGENERATIONS OF THE SPINAL CORD.i 

It is a well-recognized fact that disease of an organ pro- 
motes its atrophy and degeneration. A muscle, which from 
any cause is rendered incapable of contracting, becomes 
smaller, and its fibrillse undergo conversion into fat. The 
same law applies to other organs, and among them the spi- 
nal cord. Whatever interrupts the passage of the normal 
excitations through its columns causes degeneration. Thus, 
if there be a cerebral haemorrhage, preventing the action of 
the brain on the muscles, the anterior columns of the cord, 
not being stimulated by their accustomed excitation, under- 
go the change mentioned. If the cord itself be the seat of 
a lesion, or the posterior nerve-roots, and perhaps even the 
nerves or muscles, the posterior columns above, no longer 
being required to convey impressions to the brain, suffer 
atrophy and degeneration. To this alteration, which is not 
itself a primary disease, but which is always, in its very na- 
ture, consecutive to lesions in superior or inferior parts of 
the nervous system, the term secondary degeneration has 
been applied. 

The fact that the spinal cord is affected by lesions of the 
brain was observed by Cruveilhier, 2 who, however, failed to 

1 This chapter is mainly a condensation of the admirable memoir on the 
same subject, by M. Ch. Bouchard, published in the Archives Gen. de Med., 
1866. This memoir has been translated by Dr. E. R. Hun, of Albany. 

2 Anatomie Pathologique, liv. xxxii., p. 15. 



524 DISEASES OF THE SPINAL COED. 

notice any consecutive change in the cord below the decus- 
sation of the pyramids. 

L. Tiirck was the first specially to inquire into this 
important subject, and, in a series of memoirs extending 
through the years from 1851 to 1855, he showed that the 
cord underwent secondary degeneration, both from lesions 
of the brain and of its own substance. Since these me- 
moirs, other pathologists, among whom MM. Charcot, Tur- 
ner, Rokitansky, Yulpian, Cornil, and Lancereaux, may be 
mentioned, reported cases, but no one has investigated the 
subject with so much thoroughness as M. Bouchard. 

Symptoms. — The most important symptoms referable to 
secondary degeneration of the cord from cerebral lesions 
are muscular contractions. These are not the contractions 
which sometimes exist from the very inception of a haemor- 
rhage, for instance, but those which come on at a later 
period of the disease, and which, like the first, have gener- 
ally been thought the consequence of irritation existing 
about the cicatrix. Bouchard, however, shows very clearly 
that they are the result of secondary changes taking place 
in the spinal cord, and the clinical history of which has not 
hitherto been carefully studied. They are very frequent. 
Of thirty-two cases of old hemiplegia analyzed by Bou- 
chard, they were present in all but one. From my own 
experience I think it is safe to say that it is very rare to 
meet with a case of hemiplegia of over a year's duration in 
which they do not exist. 

In examining a patient suffering from an old hemiplegia, 
it is common to find the forearm of the paralyzed side flexed 
to some extent on the arm. Frequently, also, the fingers 
are bent into the palm of the hand, the hand flexed on the 
forearm, and the whole member carried across the front of 
the body, and held firmly against it by the contraction of 
the pectoralis major muscle. In such a case we find the mus- 
cles atrophied, hard, and stretched to an extreme degree of 
tension. Rectification of the position is, to a great extent, 



SECONDARY DEGENERATIONS OF THE SPINAL CORD. 525 

impossible by the voluntary efforts of the patient. He may 
be able to accomplish a little motion, and to do still more 
by using the sound hand to extend the affected arm ; but, if 
the hemiplegia has been of considerable duration, the range 
of his motility, with or without assistance, is very small, 
and is sometimes nothing. I have found that the electric 
contractility of such muscles is diminished in some of their 
fibres, unaffected in others, and exalted in others, so that, 
when the electrical stimulus is applied, a hard, irregular, 
and knotty contraction is obtained. 

This condition is much more common in the muscles of 
the upper extremity than in those of any other part of the 
body. The muscles of the trunk are never involved, and, 
unless, as Bouchard appears to think, the muscles of the face 
are occasionally affected, the difficulty is entirely confined 
to the extremities. Of these, the upper are much more 
frequently its seat. Thus, of the thirty-one cases of rigidity 
with contraction, studied by Bouchard, the upper extremity 
was implicated in all, and the lower but in fourteen. In 
none of his cases was the lower extremity affected without 
the upper also participating, and he lays this down as an in- 
variable occurrence. I have, however, a patient now under 
my charge, a gentleman from the West, who iive years ago 
had an attack of cerebral haemorrhage which rendered him 
hemiplegic on the left side. There is not the slightest con- 
traction of the muscles of the left upper extremity, but the 
toes of the left foot are strongly flexed, and the sole of the 
foot turned inward by the contraction of the flexor longus 
digitorum, and the tibialis posticus. 

In a case also now under my charge, the upper extremity 
is not carried across the front of the body, but is drawn 
backward by the contraction of the latissimus dorsi. 

The period at which these secondary contractions begin 
in cases of hemiplegia has been carefully studied by Char- 
cot, and he has ascertained that they habitually make their 
appearance during the second month. The fingers are usu- 



526 DISEASES OF THE SPINAL CORD. 

ally the first to be affected from the contraction of the flexor 
muscles in the forearm. A symptom mentioned by Bou- 
chard, as sometimes occurring, a trembling in the arm when 
it is raised, I have witnessed several times. 

"When the cord itself is the seat of primary disease, the 
anterior columns below undergo degeneration, and muscles 
become permanently contracted. Many cases of distortion 
which ensue on sclerosis, tumors, and other lesions, are the 
result of this secondary degeneration. M. Charcot is of the 
opinion that the epileptiform attacks sometimes met with in 
hemiplegics may result from these secondary descending 
degenerations affecting the peduncles, the pons, and the 
medulla oblongata. 

No symptoms referable to ascending secondary degen- 
erations — those of the posterior columns — have been recog- 
nized. 

Causes. — Secondary degeneration of the spinal cord may 
result from primary lesions of the cerebral hemispheres, of 
the cerebral peduncles, of the pons Yarolii, of the medulla 
oblongata, of the spinal cord itself, and of the posterior roots 
of the spinal nerves. The immediate causes are the loss of 
the due supply of arterial blood, and the arrest of nutritive 
action from deficient nervous influence. 

The Diagnosis calls for no special consideration. 

Prognosis. — This is not so unfavorable as might at first 
sight be supposed. Bouchard concludes that a cure is pos- 
sible even in severe cases. In five cases which came under 
his observation, and in which there was complete paraplegia 
due to the compression of the cord in Pott's disease, com- 
plete cures were obtained in four, and a partial cure in the 
other. In the four entirely successful cases as regards the 
restoration of sensibility, and the power of motion to the 
paralyzed limbs, there were contractions. He therefore 
concludes that the nerve-fibres of the cord, like those of the 
peripheral nerves, may be regenerated. 

My own experience is to the same effect. In cases of 



SECONDARY DEGENERATIONS OF THE SPINAL CORD. 527 

muscular contractions resulting from cerebral haemorrhage, 
and secondary degeneration of the cord, and in like diffi- 
culties due to primary lesion of the cord itself, followed by 
secondary degenerations, I have several times succeeded in 
effecting the complete relaxation of the contracted muscles, 
and the entire restoration of sensibility and the power of 
motion to the paralyzed limbs. 

Morbid Anatomy and Pathology. — Secondary degeneration 
is only found in the white substance, the gray being always 
unaffected. This might certainly have been expected, owing 
to the fact that it is the conducting power of the cord only 
that is lessened, and, as this power resides entirely in the 
fasciculi of the white substance in the antero-lateral and 
posterior columns, it is here that we find the lesions. When 
a fibre belonging to the white substance is injured, either in 
the cord or in its intra-cranial prolongations, the secondary 
degeneration ensues either above or below the seat of the 
primary lesion, but it extends through the entire length of 
this portion to its central or peripheral extremity, according 
as it involves sensory or motor filaments. To these two 
varieties, the terms ascending and descending degeneration 
are applied. The affected fibres alone are changed, and the 
alteration extends throughout their whole length. But, as 
the white fibres are constantly receiving other fibres which 
have had no initial injury, the secondary degeneration be- 
comes relatively less the greater the distance is from the seat 
of the primary lesion. 

The morbid condition depends upon three processes: 
atheroma of the capillaries and the formation of granular 
corpuscles in the degenerated tissue ; the degeneration and 
atrophy of a greater or less number of nervous filaments ; 
the proliferation of connective tissue which takes the place 
of the nerve-tubes. These changes are similar to those 
which occur in the several forms of sclerosis, to which at- 
tention has already been directed. 

Treatment. — Nothing is said by Bouchard relative to the 



528 DISEASES OF THE SPINAL CORD. 

treatment. I have obtained the best results from the use 
of the primary galvanic current to the cord, the same or the 
induced current to the muscles, forcible extension and flex- 
ion of the contracted limbs, and the internal administration 
of nitrate of silver, chloride of barium, and cod-liver oil. It 
will generally be found that the opposing muscles are more 
or less paralyzed, and that great good may be effected by 
stimulating them with the primary or induced currents. 
The division of tendons is never necessary, unless for the 
rectification of distortions of the toes or fingers. Sometimes 
the toes are strongly flexed against the sole of the foot, ren- 
dering it almost impossible to walk, from the pain produced 
by the dorsal surface being brought in contact with the 
ground, and hence obliged to bear the weight of the body. 
In such cases the tendons may with propriety be divided, 
unless the toes can be kept extended by some convenient 
prothetic apparatus. 



CHAPTEE XI. 

TETANUS. 

Two varieties of tetanus are generally described by sys- 
tematic writers — the idiopathic and the traumatic ; but, as 
they are characterized by similar phenomena, differing 
mainly as to their modes of origination and severity of their 
symptoms, there would be no advantage in considering 
them separately. 

Symptoms. — The first symptom to make its appearance 
in cases of tetanus is a feeling of pain or oppression in the 
epigastric region. In the beginning it does not attract 
much attention, but, as the disease advances, it becomes 
exceedingly severe, and adds greatly to the discomfort of 
the patient. 

Soon after the occurrence of this pain, uneasiness is gen- 
erally observed about the throat. This is, perhaps, no more 
than a sense of stiffness of the muscles concerned in deglu- 
tition, but it is not long before swallowing is impeded to a 
considerable extent. With these symptoms there are or- 
dinarily mental and physical depression, sensations of chil- 
liness, and a general feeling of malaise. 

The foregoing constitute a prodromatic or formative 
stage, which may last a few hours or several days, and 
which is occasionally overlooked when the disease is in- 
tense and rapid in character. 

In the next stage the epigastric pain is still a prominent 
symptom. It is seated just below the sternum, and gener- 
ally extends backward to the spinal column. It appears to 
34 



530 DISEASES OF THE SPINAL CORD. 

be due to spasm of the diaphragm, so that this muscle is 
among the first, if not the very first, to be affected in the 
vast majority of cases. The difficulty of swallowing in- 
creases, and then the muscles of the jaws become contracted, 
constituting the condition known as trismus or lockjaw. 
At first there is only stiffness of these muscles with those 
of the neck, but gradually they become rigid, and the pa- 
tient experiences difficulty, if not impossibility, in opening 
the mouth. The facial muscles do not escape, and an ex- 
pression like the risus sardonicus is produced from the re- 
traction of the angles of the mouth, the elevation of the 
alge nasi, and the expansion of the nostrils. At the same 
time the eyes are staring, the brows corrugated, and the 
countenance anxious or wearied in appearance. 

Sometimes gradually, at others suddenly, the morbid ac- 
tion extends to other muscles. Generally it passes to those 
of the neck, the back, and the loins, causing violent con- 
traction, and bending the body backward. This state is 
called opisthotonos. The contraction of the powerful 
muscles referred to is so great as to cause the body to as- 
sume the form of an arch, the head being thrown far back, 
the abdomen protruded, and thus, if the patient were placed 
on his back, only the occiput and heels would touch the bed. 
Opisthotonos is the usual variety of spasm. 

Two other forms are occasionally met with. In one of 
these — emprosthotonos — the body is bent forward from the 
contraction of the thoracic, abdominal, and pelvic muscles. 
In the other — pleurosthotonos — it is bent laterally. This 
latter may be met with in opisthotonos, owing to the 
muscles on one side being more strongly affected than on 
the other. Both emprosthotonos and pleurosthotonos are 
rare. Of very many cases of tetanus that have been un- 
der my observation, I have only seen the former four and 
the latter three times. The spasms characteristic of the 
disease are tonic ; but, though they do not entirely relax, 
they are marked by more or less exacerbation, according to 






TETANUS. 531 

the severity of the attack, and the care taken of the patient. 
Any cause calculated to excite reflex action will induce an 
accession. Thus the contact of the bedclothes with the 
body — the legs especially — the touch of the hand, the forci- 
ble shutting of a door, the rumbling of carriages in the 
street, even the blowing of a breath of air on the skin, may 
produce an aggravation of the spasm. Even without any 
aj>parent excitation these fits occur. They are marked by 
great pain, and may be so violent as to break the teeth, and 
the bones of the legs, and tear the large muscles of the thighs. 
During their continuance, and often when they are not pres- 
ent, the pain at the pit of the stomach becomes unendurable, 
and the patient may lose consciousness through its intensity. 
I have several times seen this event occur. 

The tonic rigidity of the muscles of respiration in- 
duces difficulty of breathing, and the same result may 
ensue from spasmodic closure of the glottis. Death has 
frequently taken place suddenly from one or other of these 
causes. 

With all this muscular excitement and mental disturb- 
ance there is rarely any fever. The skin is hot, and the 
thermometer often ranges from 105° to 110° Fahr., but the 
pulse is frecpently small and weak. 

Owing to the difficulty of swallowing, the patient suffers 
from hunger and thirst, and thus the powers of the system 
are still further reduced. The bowels are always obstinate- 
ly constipated. 

Wakefulness is generally present from the first. When 
the patient does sleep, it usually happens that the muscles 
are relaxed, to be again suddenly affected with spasm as soon 
as he awakes. 

The mind is clear throughout, even in the most severe 
cases. When loss of consciousness occurs from extreme 
pain, it is from syncope, and not from any implication of 
the brain in the essential nature of the disease. Death usu- 
ally takes place by apncea. It may, however, result from 



532 DISEASES OF THE SPINAL CORD. 

exhaustion, and, according to some authorities, from the 
spasmodic action attacking the heart. 

The duration of the disease is very variable. The short- 
est case on record is one observed by Prof. Robinson, of 
Edinburgh. The patient, a negro waiter, cut his finger 
with a piece of broken china. He was immediately seized 
with tetanus, and died within fifteen minutes. Mr. Poland 
quotes a case in which death took place in iive hours ; in a 
case cited by Lepelletier in a few hours ; in one by Dr. 
Jackson in twelve ; in one by Dr. Leith in eighteen ; and 
in one observed by Mr. Curling in nineteen. 1 

The shortest duration in any case I have witnessed was 
twenty-six hours, though I believe there were several much 
shorter, which occurred during the recent war in this coun- 
try. 

The average period of duration in fatal cases is from the 
third to the fifth day. Instances in which it has been pro- 
longed far beyond this limit are not uncommon. Hennen 2 
reports a case in which it lasted six weeks, and then the 
patient died of another disease. He reports another case in 
which it lasted seven weeks, and ended in recovery. I have 
seen three cases in which it extended to the fifth week. 

The period which elapses between the reception of the 
cause and the beginning of the symptoms is also subject to 
great variation. In a case already cited it was only fifteen 
minutes ; in another, quoted from Dr. Randolph by Reeves, 3 
the spasms ensued immediately after the patient was stung 
by a bee ; and in another, which occurred in his own ex- 
perience they came on in a sensitive female immediately after 
running a needle into her finger. There is doubt, however, 
as to such cases really being tetanus. In the last one cited it 

1 All the above instances are quoted from Reeves's Diseases of the Spinal 
Cord and its Membranes, London, 1858, p. 387, et seg. 

2 Observations on some Important Points in the Practice of Military Sur- 
gery, etc. Edinburgh, 1818, p. 263. 

3 Op. cit., p. 377. 



TETANUS. 533 

is stated that " the body and extremities were rigid, mouth 
closed, and the jaws fixed, the eyes the same. At short in- 
tervals the whole body was affected with convulsive shocks ; 
the administration of a dose of chloroform removed them, 
but the back and neck remained rigid for three days." 
This attack was probably a manifestation of hysteria. In 
eighty-one cases collected by Mr. Curling, the disease began 
between the fourth and fourteenth days, both inclusive, and 
in nineteen on the tenth day. The following table from 
Reeves shows the period of the occurrence of the disease in 
three hundred and forty-three cases : 

Within six, twelve, eighteen, or twenty-four hours. . . 12 

From 1 to 2 days 12 

" 3 to 5 " 37 

" 6 to 8 " 94 

" 9 to 12 " 77 

" 12 to 14 " 52 

" 15 to 17 " 25 

" 18 to 20 " 9 

" 21 to 23 " 9 

" 24 to 26 " 6 

" 27 to 29 " 9 

" 30 to 32 " 1 

343 

Causes. — The most common cause of tetanus is bodily 
injury of any kind, from the slightest to the most severe, 
and of any part of the body, although wounds of some 
parts, as of the thumb and great toe, are more apt to be fol- 
lowed by the disease than those of other regions. It has 
been known to result from the bite of a tame sparrow, from 
the sticking of a small fish-bone in the pharynx, from a 
seton in the thorax, from the stroke of a cane across the 
back of the neck, from the blow of a whip-lash, from frac- 
tured bones, and from every other imaginable wound or in- 
jury. In a case under my chargS in this city, it was caused 
by a splinter of wood slightly scratching the palm of the 



534 DISEASES OF THE SPINAL CORD. 

hand, in another a slight punctured wound of the foot pro- 
duced it. 

Next in frequency to wounds, tetanus is induced by 
exposure to cold and damp. This is the exciting cause in 
the great majority of cases of idiopathic tetanus, and it in- 
creases liability in those who have suffered from wounds. 
It was not uncommon, during the recent war, for the num- 
ber of cases of tetanus to be very much increased immedi- 
ately after a sudden change of the weather from dry and 
mild to wet and cold. 

It has also apparently been caused by worms, by abor- 
tion and labor, and by diseases of the womb. Terror has 
the reputation of having induced tetanus in one case report- 
ed by Dr. Willan, and in others observed by Hennen. 

In the form occurring in very young children, and known 
as trismus nascentium, it appears to be induced by inatten- 
tion to the cut umbilical cord. 

The tendency to tetanus, especially among soldiers and 
others who have been wounded, is increased by poor diet, 
confinement in ill-ventilated hospitals, inattention to clean- 
liness, and neglect to give proper care to the wounds they 
may have received. 

Diagnosis. — The only affections with which tetanus is 
liable to be confounded, by any but the most ignorant, are 
the hysterical simulated affection, and the condition in- 
duced by poisoning with strychnia and other substances of 
its class. 

That hysteria can simulate tetanus, as well as almost all 
other diseases, we have abundant evidence. A case has 
already been referred to in this chapter which was evidently 
hysterical, and several others have come under my observa- 
tion. A lady now under my charge has repeated attacks of 
hysterical spasms, during which her jaws are tightly closed, 
she is unable to swallow, and her body is bent backward so 
as to assume the position of opisthotonos. 

Such seizures are readily distinguished from tetanus by 



TETANUS. 535 

the facts that they are unaccompanied by pain or real dis- 
tress, are of very transient duration, and are accompanied 
by other manifestations of hysteria. 

From the artificial tetanus caused by strychnia, the diag- 
nosis is more difficult ; for, so far as the more obvious symp- 
toms go, there is such a great similarity that even the most 
skilful diagnosticians might be, for a time, undecided. It 
is well known that strychnia is not unfrequently used for 
the purpose of committing murder or suicide, and it is pos- 
sible so to employ it for either of these purposes as to cause 
its effects to extend over a long period of time, and thus to 
add to the difficulties attending the discrimination. Even 
in such a case, however, the diagnosis can be made if due 
care and a thorough inquiry into the history of the case be 
made. 

In the first place, the tetanus of strychnia always shows 
itself in the lower extremities before trismus ensues. The 
legs are stretched widely apart, and the hands are generally 
involved. In natural tetanus, trismus precedes spasm in 
the extremities ; indeed, the lower extremities are rarely 
affected to any great extent. The arms generally escape 
altogether. 

The epigastric pain, which constitutes so prominent a 
feature of true tetanus, is not present in the toxic variety. 
I have witnessed three cases of poisoning by strychnia, and 
this pain was not complained of in either of them. 

In the tetanus of strychnia, the symptoms are developed 
with great rapidity, and death takes place generally within 
a half an hour, although life may be prolonged, in excep- 
tional cases, somewhat beyond this peried. In true tetanus 
it is very rarely the case that death takes place within twelve 
hours, and ordinarily not till several days have elapsed. 

In those cases of poisoning by strychnia in which the 
doses have been small, and administered at comparatively 
long intervals, the symptoms are mitigated in violence, and 
consequently one of the distinguishing features of the two 



536 DISEASES OF THE SPINAL CORD. 

affections is lost. Still, the general character and sequence 
of the phenomenon are the same, and it is not probable that 
careful observation and inquiry will fail to elicit i;he true 
nature of the case. 

Prognosis. — The longer the time that has elapsed between 
the reception of the injury or subjection to other cause, the 
greater is the probability of a favorable termination. When 
the paroxysms are slight, and the intervals between them 
long, the prognosis is also more favorable. The duration 
of the disease is likewise an important element in the prog- 
nosis; and, when it has lasted over a week, death does not 
often take place. Cases are, however, on record in which a 
fatal result has supervened after the affection has existed for 
several weeks. 

Tetanus is, nevertheless, one of the most fatal of mala- 
dies. Dr. O'Beirne * witnessed two hundred cases without 
a single recovery. Hennen 2 never saw a case of acute 
symptomatic tetanus recover. McLeod 3 has collected and 
analyzed twenty-three cases which occurred in the British 
army in the Crimea, of which but two recovered. Demme* 
refers to eighty-six cases in the hospitals in Italy during 
the campaign of 1859, of which six were cured; and 
Hamilton 6 has observed eight cases, of which three re- 
covered. 

ISTine cases have been under my immediate care, of 
which there were three recoveries. Of the many cases 
which I observed in the course of my inspections of camps 
and hospitals in the army during the recent war, I do not 
know how many terminated favorably. I am disposed, 
however, to believe that the number was not great. Ham- 
ilton states that his information leads him to think that, of 

1 Dublin Hospital Reports, vol iii., pp. 343, 3*78. 2 Op. cit., p. 262. 

8 Notes on the Surgery of the War in the Crimea, London, 1858, p. 153, et 
seq. Also table, p. 439. 

4 Militar-Chirurgische Studien, Wtirzburg, 1861. 

5 A Treatise on Military Surgery and Hygiene, New York, 1866, p. 595. 



TETANUS. 537 

one hundred and fifty cases which occurred during the war, 
the recoveries were few. 

Morbid Anatomy and Pathology. — The results of post-mor- 
tem examination of patients who have died of tetanus are 
very unsatisfactory. Rokitansky, 1 in chronic cases, has 
found a proliferation of connective tissue in the spinal cord. 
Wedl, 2 in one case, discovered increased redness of a por- 
tion of the spinal cord. Curling 3 declares that serous effu- 
sion with increased vascularity is generally observed in the 
membranes investing the medulla spinalis, and also a turgid 
state of the blood-ves&els above the origin of the nerves ; 
and Lockhart Clarke 4 regards the constant lesion as con- 
sisting of a granular degeneration of the cells of the 
cord. 

On the other hand, it often happens, especially in 
very rapid cases, that nothing is found which can fairly be 
regarded as constituting the essential feature of the disease. 
Billroth 6 affirms that his examinations of the spine and 
nerves, in cases of tetanus, have thus far given only nega- 
tive results, and this is in accordance with the observations 
of the great majority of pathologists. While, therefore, 
there appears to be no doubt that the disorder is dependent 
upon some lesion of the spinal cord, and probably of the 
gray matter, our examinations have not as yet enabled us 
to determine the nature of the morbid process. 

It is contended by some authors that tetanus, like hydro- 
phobia, is due to blood-poisoning. The fact, that a condition, 
so nearly resembling it as to be with difficulty diagnosti- 
cated from it, may be caused by the injection of strychnia 
into the blood, appears to favor this view. However this 

1 Beitrage zur Pathologie des Tetanus. Virchow's Archiv, t. xxvi., 1862. 

2 Rudiments of Pathological Histology. Sydenham Society Translation. 
London, 1855, p. 276. 

3 A. Treatise on Tetanus, etc., London, 1836. 

4 Lancet, 1864, and Medical Times and Gazette, 1865. 

5 General Surgical Pathology and Therapeutics, in JFifty Lectures. Hack- 
ley's Translation. New York : D. Appleton & Co., 1871, p. 353. 



538 DISEASES OF THE SPINAL COED. 

may be, the character of the symptoms indicates the spinal 
cord to be the seat of the disease. 

The spinal cord is both an organ for the generation of 
nerve-force, and for conducting impressions to and from the 
brain. In tetanus it is this first-named function which is 
deranged, and this is shown by the great exaltation of reflex 
excitability which exists. Every thing capable of causing a 
reflex movement of the slightest kind, and even excitations 
which in health would be altogether unperceived by the 
cord, augment its intrinsic action to a great extent where 
tetanus exists. 

Now, we are able to produce a similar increase of reflex 
action by strychnia ; and, in those cases of disease in which 
the amount of blood in the cord is increased, very small 
quantities of strychnia produce the characteristic phenomena 
of stiffness in certain muscles, and of augmented reflex ex- 
citability. The condition is aggravated by the medicine ; 
and, if we had no other facts to support the theory, we 
should be warranted in concluding that, in cases of strych- 
nia-poisoning, the amount of blood in the cord and the 
excitability of the organ are both increased. From a con- 
sideration of all the points bearing on the subject, we are 
warranted in concluding that tetanus essentially consists in 
a morbid exaltation of the functions of the spinal cord as a 
nerve-centre. 

Bernard * has investigated this matter with his usual ex- 
actness. He says : 

" Strychnia produces convulsions by exaggerating the 
sensibility of certain parts ; it also causes reflex movements. . 
We have seen that the point of departure is in the sensitive 
system ; for, where the posterior roots of the nerves are cut, 
the animal dies without convulsions." 

An experiment performed by myself and my friend and 

1 Le9ons sur les Effets des Substances toxiques et medicamenteuses, Paris, 
1857, p. 386. 



TETANUS. 539 

collaborator, Dr. S. Weir Mitchell, 1 shows that the action 
of strychnia is to destroy the nervous excitability from the 
centre to the periphery. Its influence, therefore, must first 
be exerted on the spinal cord. 

" Under the skin of a large frog, whose left sciatic nerve 
was previously divided, a few drops of a strong solution of 
strychnia were introduced. Tetanic spasms ensued in two 
minutes. After forty-five minutes the nerves were irritated 
by galvanism. That of the left side, which had been cut, 
responded energetically, while no motions could be pro- 
duced through the uncut nerve. The former remained ex- 
citable for two hours later." 

Bernard a asserts that the action of strychnia extends no 
farther than the spinal cord ; and any one who has seen a 
frog under the influence of this substance cannot have failed 
to notice that all the symptoms indicate exalted spinal ac- 
tion. 

We are therefore led by observation and experiment to 
the conclusion that tetanus is seated in the spinal cord, and 
that, although we cannot at present affirm an identity of 
lesions, in each case we shall probably eventually be able to 
define them with as much accuracy as we do those of other 
spinal diseases which a few years since were equally ob- 
scure. 

Treatment. — There is scarcely a sedative or stimulant 
remedy in the pharmacopoeia which has not been employed 
and recommended in tetanus. Aconite, ether, belladonna, 
chloroform, cannabis Indica, conium, opium, tobacco, Cal- 
abar bean, ice, counter-irritants, alcohol, and many other 
substances, have been used, and cases reported which have 
apparently recovered under their administration. Then, of 
surgical means, excision of the injured nerve and amputa- 

1 Experimental Researches relative to Corroval and Yao ; two new Varie- 
ties of Woorara, the South American Arrow-Poison. American Journal of the 
Medical Sciences, July, 1859. Also Physiological Memoirs, Philadelphia, 1863, 
p. 181, etseq. 2 Op. cit., p. 359. 



540 DISEASES OF THE SPINAL CORD. 

tion of the wounded member have also been recommended, 
but are not, I believe, practised now. Latterly the bromide 
of potassium and hydrate of chloral have been employed 
with favorable results. 

A case in which the latter agent was successfully used 
in tetanus is reported by Dr. Wirth, 1 of Columbus, Ohio. 
In about a month the patient took nine ounces and two 
drachms, in doses of from thirty to forty grains, at times as 
often as every one and a half hour. In this case opium in 
large doses had been administered without effect. A num- 
ber of other cases in which chloral was administered are 
cited in the same number of the New York Medical Jour- 
nal in which Dr. Wirth's case appears, in several of which 
it was successful. 

A very thorough analysis by my friend Dr. D. W. Yan- 
del], 3 of Louisville, of an unpublished report on tetanus, by 
Dr. R. O. Cowling, embraces so much valuable information 
on the subject that I quote the summary entire. The term 
acute is applied to tetanus occurring within nine days of the 
injury, and chronic to cases ensuing after nine days : 

" Calabar bean was given in thirty-nine cases, with 
thirty-nine per cent, of recoveries. Of these reported cures, 
but one was of acute tetanus ; five others were in cases 
which recovered before the expiration of fourteen days. 
Per contra^ there were ten deaths from chronic tetanus. 

"Indian hemp used in twenty-five cases, with sixty- 
four per cent, of recoveries, of which three cases were 
acute, and six recovered before the symptoms lasted four- 
teen days. 

" Chloroform relieved seventy per cent, of thirty-five 
cases, nine of which were acute, and eight recovered before 
fourteen days. Three chronic cases died, and two after 
symptoms lasted fourteen days. 

"Ether. — Sixty per cent, of fifteen cases recovered ; five 

1 New York Medical Journal, November, 1870, p. 419. 

2 American Practitioner, September, 1870, p. 152. 



TETANUS. 541 

acute ; seven inside of fourteen days. One chronic case 
died. 

" Opium. — Fifty-seven per cent, of one hundred and 
sixty -five cases recovered ; twenty-two acute ; twenty-nine 
before the fourteenth day. Twenty-six chronic cases were 
lost, and four after the disease had continued fourteen days. 

" Tobacco relieved fifty per cent, of forty-one cases ; six 
acute ; six before fourteen days of the disease. Four chronic 
cases died, and one after fourteen days. 

" Quinine. — Seventy-three per cent, of fifteen cases re- 
covered ; one acute ; three before fourteen days. Three 
chronic cases ended fatally, and one after fourteen days' 
duration. 

"Aconite. — Eight per cent, of fourteen cases recovered ; 
none acute ; none recovered before fourteen days. Death 
in one chronic case. 

" Stimulants. — Eighty per cent, of thirty-three cases re- 
covered ; four acute ; six within fourteen days. Six chronic 
cases died, and three after fourteen days. 

"Mercury. — Fifty-seven per cent, of seventy-five cases 
got well ; twelve before fourteen days. Seventeen chronic 
cases were lost, and two after fourteen days. 

" Bleeding. — Fifty- five per cent, of fifty-eight cases re- 
covered ; nine acute ; ten before the fourteenth day. Seven 
chronic cases were lost, and two after fourteen days. 

" Cold Affusion. — Seventy-three per cent, of eleven cases 
recovered ; three acute ; three before fourteen days. Two 
chronic cases died. 

"Ice-bags. — Seventy-seven per cent, of nine cases recov- 
ered ; one acute ; two in less than fourteen days. 

"Amputation. — Sixty per cent, of seventeen cases re- 
covered ; four acute ; four in less than fourteen days. Three 
chronic cases died, and one after fourteen days. 

"Division of nerve relieved seventy-five per cent, of 
three cases ; one acute ; one before the fourteenth day. 
One chronic case died. 



542 DISEASES OF THE SPINAL CORD. 

" Purgatives. — Sixty-six per cent, of seventy-four cases 
recovered ; thirteen acute ; twelve before fourteen days. 
Ten chronic cases died, and three after fourteen days. 

" Turpentine relieved seventy per cent, of sixteen cases ; 
six acute ; four before fourteen days. Five chronic cases 
died, and two after fourteen days." 

Among the conclusions arrived at by Dr. Yandell from 
these data are, that "recoveries from traumatic tetanus 
have been usually in cases in which the disease occurs sub- 
sequent to nine days after the injury ; that when the symp- 
toms last fourteen days recovery is the rule, and death the 
exception, apparently independent of the treatment ; that 
chloroform, up to this time, has yielded the largest per cent- 
age of cures in acute tetanus ; that the true test of a remedy 
for tetanus is its influence on the history of the disease : 
does it cure cases in which the disease has set in previous to 
the ninth day % does it fail in cases whose duration exceeds 
fourteen days % and that no agent, tried by these tests, has 
yet established its claims as a true remedy for tetanus." 

It is, perhaps, scarcely necessary to say that I fully ac- 
cord with these opinions. 

Judging from its effects upon the spinal cord, it was sup- 
posed by Mr. Morgan that woorara injected into the blood 
might prove efficacious in tetanus. Experience, however, 
has not confirmed this view ; and the researches of Dr. Cow- 
ling show that it is one of the most inefficient of remedies. 

In a case which was under my charge ten years ago, 
when I was one of the surgeons of the Baltimore Infirmary, 
I injected corroval — a remedy which the investigations of 
Dr. Mitchell and myself had proved to be antagonistic to 
strychnia — into the blood. The patient, a colored boy, be- 
came affected with tetanus two days after his arm had been 
amputated by my friend and colleague Prof. Nathan R. 
Smith. Cannabis Indica, morphia, and chloroform, had been 
used without effect, when at my request Prof. Smith turned 
the case over to me, in order that corroval might be admin- 



TETANUS. 543 

istered. Two drops of a strong solution of the substance in 
water were injected into the cellular tissue of the forearm. 
At the time the pulse was 160, and the respirations about 
75. There was very decided opisthotonos. In three min- 
utes the pulse had fallen to 152. Two more drops were 
then injected, and the pulse fell to 144. As it soon rose 
again, two more drops were injected, when it fell to 132, 
and the respirations to 64. The spasms still continu- 
ing, two more drops were injected. In five minutes the 
pulse began to decline rapidly, and in ten minutes had fallen 
to 90. At this time the patient had a violent tetanic spasm, 
and during its continuance the pulse became intermittent. 
It then rapidly went down to 40, then to 30, and during a 
violent spasm the patient died. From this record it will be 
seen that at no time did the corroval exercise the least effect 
over the disease. 1 

As I have stated, three successful cases have occurred in 
my practice. One of these I saw in consultation with Dr. 
J. Lewis Smith, of this city. It was traumatic, and had en- 
sued two weeks after a wound of the foot by a nail. The 
patient was treated by cannabis Indica, and the persistent 
application of ice to the spine. The spasms were greatly 
lessened in force and frequency, and recovery took place 
within two weeks. Another, which was also traumatic and 
acute— that is, making its appearance within nine days after 
the injury — was treated according to the same plan, and re- 
covered in sixteen days, though the jaws remained stiff for 
several weeks afterward. The wound was caused by an ice- 
pick being accidentally thrust through the hand. The third 
case was that of an eminent musician of this city, who, 
while drilling with the regiment to which he belonged, in- 
jured his thumb with a splinter from the stock of his rifle. 
The first evidence of tetanus appeared on the twelfth day. 

1 Traumatic Tetanus. Inoculation with Corroval. Death. By Edward Mil- 
holland, M. D., Resident Physician at the Baltimore Infirmary. In Maryland and 
Virginia Medical Journal, January, 1861, p. 13. 



544 DISEASES OF THE SPINAL CORD. 

The attack was not very severe. I administered the extract 
of cannabis Indica (Squires's) in doses of half a grain every 
two hours, and kept up the application of ice to the spine 
continuously for six days. There were several violent 
spasms during this period, and the opisthotonos was well 
marked. At the end of a week the cannabis Indica was 
omitted for a day, but, the spasms becoming more frequent 
and severe, it was resumed as before, and continued with 
tolerable regularity for ten days longer. During this period 
there were but two spasms, and the opisthotonos became 
less. It was then gradually diminished, and on the twenty- 
fifth day was left off altogether, the patient being convales- 
cent. 

I am disposed to think that, whatever internal medication 
be adopted, the application of ice to the spine is a measure 
which should always form a feature of the treatment. 



SECTION III. 
CEBEBKO-SPIN"AL DISEASES. 



CHAPTEE I. 

HYDROPHOBIA. 

Althotoh there are objections to the name employed to 
designate the terrible disease I now propose to consider, the 
same is true of all other terms which have been applied to 
it, and the present has the advantage of being well known. 
So long as we are obliged, through ignorance of pathology 
and morbid anatomy, to use a nomenclature based on symp- 
toms, we must expect" to T5e inexact. The name hydropho- 
bia is as old as Galen, and still retains its preeminence, not- 
withstanding the fact that the symptom on which it is based 
is sometimes absent. 

Symptoms. — Beginning with the reception of the injury 
by which the body has been inoculated, we find that it heals 
in the ordinary way, and that there are no immediate signs 
of infection. At a period which varies greatly in different 
cases, pain or a sensation of uneasiness is usually experienced 
at the seat of the woimd. This, however, is rarely of such 
intensity as to cause suffering, and probably would generally 
be overlooked or disregarded but for the apprehension which 
the patient has, and which directs his attention to every sen- 
sation which can be attributed to the wound. But there 
35 



546 CEREBROSPINAL DISEASES. 

may be absolutely no pain or uneasiness other than such as 
are met with in all wounds till the phenomena of the affec- 
tion are manifested. The period between the reception of 
the injury and the beginning of the symptoms of hydropho- 
bia is known as the stage of incubation. 

The duration of this stage is variable. It is rarely short- 
er than a month, and probably never longer than two years. 
Instances are on record, however, in which the disease has 
been developed within ten days, and others, about which, 
however, there is much doubt, in which the latent period has 
reached to ten years and longer. The vast majority of cases 
occur within seven months after the reception of the wound. 
In four cases which have been under my observation, the 
period of incubation varied from sixty-two days to four 
months and a half. 

During this period of incubation there are not often any 
indications of what is going to take place except in those 
cases in which there are abnormal sensations in the cicatrix 
or its neighborhood. Sometimes there are depression of 
spirits, anxiety, and derangement of the digestive functions, 
but these symptoms may fairly be attributed to the peculiar 
circumstances of the case, aside from any toxic influence 
due to infection. 

The iirst symptoms which generally appear are directly 
connected with the cicatrix, which, if it has previously been 
free from abnormal appearances and sensations, now be- 
comes subject to both. But there is no constancy even in 
these phenomena. They were altogether absent in one of 
my cases, and very slightly manifested in one other, if they 
were present at all. In this case, which I saw in consulta- 
tion with Dr. S. Gr. Cook, 1 of this city, the patient, after 
other symptoms had appeared, occasionally clutched the 
place where he had been bitten, but denied, on being asked, 
that there was any pain at the spot. 

1 A case of Hydrophobia. Journal of Psychological Medicine, January, 
1870, p. 80. 



HYDROPHOBIA. 547 

But, though there may be no symptoms of swelling, red- 
ness, or pain about the cicatrix, there are abnormal sensa- 
tions in the nerves which radiate from it. Thus, if the in- 
jury has been in the leg, pains are felt along the courses of 
the sciatic and crural nerves ; if in the hand, similar sensa- 
tions are experienced in the radial, ulnar, median, and 
other nerves of the upper extremity. Occasionally the pain 
is felt in the epigastric region, and in any situation is ordi- 
narily accompanied by headache. At about the same time 
the respiration becomes sighing and irregular, there is a feel- 
ing of oppression or constriction in the chest, the pulse loses 
its force and uniformity, and there is an indefinable sense of 
anxiety. The sleep is scarcely ever natural. Either there 
is insomnia or drowsiness, and sleep, when obtained, is dis- 
turbed by frightful dreams, and is unrefreshing. The bowels 
are constipated, the skin is dry, and there are alternate chills 
and flushes of heat. The duration of this stage is from two 
to four days. 

And then the period of full development begins ; char- 
acterized, at first, by an increase in the symptoms just men- 
tioned, and subsequently by the appearance of others not 
previously present. A peculiar sense of uneasiness is felt 
at the epigastrium, and a pain and constriction of the throat, 
which add greatly to the distress. The tongue becomes stiff 
and painful, and articulation is thereby rendered indistinct ; 
the respiration increases in irregularity, and becomes noisy 
and oppressed ; the rigidity of the muscles of the throat 
prevents or impedes deglutition, and the patient dreads at- 
tempting to swallow, from the experience he soon acquires 
that his efforts in this direction are attended with pain and 
spasm, which greatly increase his sufferings. Sometimes 
the convulsion of the pharyngeal muscles is so great that 
substances are thrown with great force out of the mouth. 
This was the case in two of the instances I witnessed. At 
the same time the spasm extends to other parts of the body, 
and occasionally becomes general. It is accompanied by 



548 CEREBROSPINAL DISEASES. 

pain in the epigastrium, and sometimes in the spine. Solids 
are swallowed with much more ease than liquids. Indeed, 
so great is the difference that the patient cannot even enter- 
tain the idea of swallowing any fluid without being thrown 
into spasms. The sound of water splashing or trickling, the 
sight of it, the thought of it, and even an impression re- 
motely connected with water, such as that produced by the 
reflection of rays of sunlight on the face by a mirror, will 
bring on a paroxysm of convulsions. With the spasm 
there are sobbings, trembling, and then a condition of ex- 
haustion, during which the patient is bathed in perspira- 
tion. 

The following day the phenomena are still more strongly 
marked. The mouth is dry and parched, and yet the pa- 
tient dare not attempt to quench his thirst ; vomiting ensues, 
the pulse becomes rapid and small, the pain in the pit of 
the stomach still increases, the headache is intense, and the 
countenance expresses terror, anxiety, and suffering. The 
pain in the spine augments and extends to the muscles of 
the neck and abdomen. The secretions of the mouth are 
altered, and the saliva is mixed with a frothy, tenacious mu- 
cus, which the patient is constantly attempting to eject, but 
which collects as fast as he can spit it out. The mouth and 
fauces are dry and painful, articulation is almost impossible, 
and every attempt to relieve the distress by a few drops of 
water induces a return of the spasms and convulsions. Fi- 
nally every reflex excitation reaches the muscles of the 
throat ; the contact of the bedclothes, the jarring of the 
bed by persons walking in the room, the rustling of window- 
curtains — any thing capable of acting on the hearing, the 
eyesight, or the touch, may cause the spasms. 

As the disease advances, all the symptoms increase in 
violence, and still others make their appearance. The urine 
and fseces are often passed involuntarily, the skin becomes 
exquisitely sensitive, the body is in a constant state of agi- 
tation and tremor, alternating with spasms, and the tough, 



HYDROPHOBIA. 549 

stringy, tenacious mucus collects in the throat and impedes 
respiration. 

Thus far the mental symptoms have scarcely been con- 
sidered, but they are present almost from the first. Indeed, 
they may be among the very first indications of disorder. 
They consist of emotional disturbances of various kinds, and 
sometimes radical changes of character and disposition. 

It has been alleged by some authors that the dreams, at 
a very early period after inoculation, are connected with 
the animal giving the wound. I have never met with this 
symptom, but in the case previously cited, and which I saw 
twice in consultation, a circumstance still more remark a- 
able is related by Dr. Cook. The patient, a child three 
years old, was bitten by a bitch in heat on or about August 
20, 1ST0. On November 15th the mother noticed that he 
slept badly ; on the 16th, among other manifestations, he 
" was cranky all day." On the 17th he was seen by Dr. 
Cook. 1 

" On entering the room," says the doctor, in his report 
of the case, " and seeing several children, and not noticing 
any thing wrong with any of them, I very naturally in- 
quired which was the patient. I was pointed to a little boy 
sitting at a table in a high chair. On approaching him, he 
turned his face toward me, revealing the most peculiar-look- 
ing eyes I have ever seen. They were not like those seen 
in persons suffering from delirium in prolonged fevers, nor 
yet like those we see in the second stage of cerebral menin- 
gitis, although somewhat resembling both of these condi- 
tions, but more like the eyes of a person in a fit of violent 
anger, slightly combined with a feeling of fear. 

" When I reached out my hand to touch his, he shrank 
from me as from a blow, at the same time making a desper- 
ate effort to catch his breath, precisely as a naked person 
might if a pail of cold water was unexpectedly poured over 
him. This I understood to be a laryngeal spasm. It was 
1 Op. cit., p. 81. 



550 CEREBROSPINAL DISEASES. 

very brief, lasting but the fraction of a minute, probably 
not more than ten seconds. I took a seat at a little distance 
from him, where I could see his every motion, and regarded 
him attentively for a long time. 

" He seemed an unusually intelligent child, for one of his 
age, speaking very distinctly with a clear, ringing voice, 
which his parents informed me was a little unnatural, as it 
' seemed strained.' He had at times a disposition to stam- 
mer, which was also unnatural. For one hour after my ob- 
servation commenced he talked almost incessantly of dogs, 
and repeated very few sentences a second time. He seemed 
familiar with all the most common breeds, relating some 
anecdote of the bull-dog, the mastiff, the bird-dog, the span- 
iel, the coach-dog, and the poodle. 

" Connected with all his narratives was a tragic or gloomy 
termination. The mastiff, after carrying him an incredible 
distance about the city, finally disappeared through a bot- 
tomless hole in the street, he only escaping a similar fate by 
suddenly dismounting. The bull-dog, after bringing for his 
admiration and pleasure a great variety of puppies, sudden- 
ly turned cannibal, and swallowed the whole lot. The span- 
iel, after having been his playmate for a very long time, 
finally took it into his heap! one day to get on to a coffin 
that was being carried through the streets, and ride away 
to reappear no more." 

There were no other evidences of disordered mental ac- 
tion in this child, and he died, perfectly conscious to the 
last. 

Usually, however, this is not the case, and various mor- 
bid desires are entertained by the patient. Thus, in a case 
which I saw in this city in 1865, there was an impulse to 
strike those near, and an intense dislike of certain per- 
sons who had always been intimate friends of the patient. 
In both the other cases there were paroxysms of previous 
delirium, during which the sufferers bit and struck at all 
within their reach, and of which hallucinations and delu- 



HYDROPHOBIA. 551 

sions constituted marked features. In the case of the boy 
just cited, the stories of dogs which he related were evi- 
dently delusions which he accepted as realities. 

Death usually takes place on the third day after the ac- 
cession of the symptoms indicating the full development of 
the disease. The chief of these is laryngeal spasm. A fatal 
termination is rarely delayed till after the third day, though 
cases are not uncommon in which it has ensued on the first 
or second day. In all the cases, except one, which have been 
under my observation, the third was the fatal day. In Dr. 
Cook's, the latest I have seen, the disease may be considered 
as having been fairly developed on the 17th of November, 
the first day in which any spasm of the throat was witnessed. 
Death resulted on the evening of the 18th. 

Generally death takes place during a spasm. This was 
the result in three of my cases. In the other — the latest — 
the child died quietly. In the former condition apncea is 
probably the immediate cause of death ; in the latter, ex- 
haustion. In all cases, the powers of life, from the violent 
convulsions, the loss of sleep, and the deprivation of food 
and drink, are drained away to the utmost. 

Causes. — It has generally been supposed that hydropho- 
bia has but one source in the human subject, and that is, in- 
oculation by the saliva of an animal affected with rabies. 
It cannot be communicated to one individual by the saliva 
of another affected with hydrophobia, although there is no 
doubt that, under certain circumstances, the saliva of man, 
as well as the milk and other secretions, may become poi- 
sonous. Neither can dogs or other animals be infected by 
inoculation with the saliva of a hydrophobic man. Ma- 
gendie's • experiment, the only one of the kind which has 
ever succeeded, is of exceedingly doubtful import, as hydro- 
phobia was prevailing among dogs at the time, and the ani- 
mal may have been previously bitten. 

1 Dictionnaire des Sciences Med. Art. Rage, t. 47, p. 46. Also Journal de 
Physiologie, t. i., p. 47. 



552 CEREBROSPINAL DISEASES. 

But it is very probable that the saliva of healthy ani- 
mals, the dog especially, is capable of producing hydropho- 
bia in man and other animals. A case of the kind is 
recorded in Huf eland's Journal of December, 1839, and 
similar ones are frequently met with. In none of the cases 
I have witnessed was the dog which had inflicted the wound 
supposed to have been rabid. In one case which I saw in 
this city, with a physician whose name I cannot recall, 
the patient, a stableman, was bitten by a dog that was to 
all appearance in perfect health. In the case reported by 
Dr. Cook, the animal, a bitch, was being led quietly through 
the passage-way of the house, when the child became en- 
tangled in the chain, fell against the dog, and was bitten 
apparently in anger. The animal was well known, and was 
not even suspected of being hydrophobic. She was in heat ; 
and Dr. Cook raises, for the first time to my knowledge, the 
question whether this circumstance renders the saliva of the 
animal capable of inducing hydrophobia in the human sub- 
ject. With a view of throwing as much light as possible 
on the subject, he consulted the records of Bellevue Hospi- 
tal, in order to ascertain the facts in relation to a man who 
died of what was supposed to be hydrophobia from the bite 
of a bitch in heat. The results of his inquiries were to show 
very certainly that the man did die of hydrophobia ; that 
the animal was not rabid, and that she was in heat. 

It would appear that the saliva is the only means of 
communication. Dupuytren, Breschet, and Magendie, en- 
deavored to convey the disease by injecting the blood of 
dogs, suffering from rabies, into the veins of healthy dogs, 
but always unsuccessfully. The flesh, milk, semen, and ab- 
dominal secretions, were likewise found not to be media for 
transmission. 

]STo other animals than those of the genera canis and 
felis have been clearly shown to be capable of communicat- 
ing the disease. The power has been claimed for the rat, 
but on insufficient evidence. The wolf is said to be the 



HYDROPHOBIA. 553 

most dangerous of all in this respect, for the reason proba- 
bly that it seizes the neck or face, parts not fully protected 
by clothing, and thus the saliva is not so apt to be rubbed 
off as when the leg, for instance, is the part attacked. 

The slightest abrasion of the skin coming in contact 
with the saliva may be sufficient for inoculation. Cases are 
recorded in which the disease has resulted from dogs licking 
the hand or face on which there were pimples or sores. 

Diagnosis. — That protean disease, hysteria, occasionally 
puts on the semblance of hydrophobia. Several cases of 
the kind have occurred to me, and in all the symptoms were 
in general character very much like those which are exhib- 
ited by genuine hydrophobia, though in some respects, per- 
haps, a little exaggerated. It will in these and similar 
cases — the result of fright and imagination — often be found 
that the patient has been bitten by a dog not long before. 
There is a want of consistency about the symptoms which 
of itself is sufficient to excite suspicion as to the real char- 
acter of the phenomena. Thus, although at times the at- 
tempt to swallow will excite laryngeal and other spasms, 
these do not always occur under similar circumstances, and 
are not induced by those secondary and more refined in- 
fluences, such as the sound of falling water, bright lights in 
the face, excitations applied to the skin, seeing others drink, 
etc., which so generally cause them in the real disease. 
There are not the same anxiety and depression in the simu- 
lated disease as in the real, though the apparent emotional 
disturbance is much greater. The hysterical patient is loud 
in the expression of apprehensions, while the real hydropho- 
bic one, though intensely anxious and terrified, endeavors 
to prevent others perceiving the state of his mind. 

The history of the case, the existence of the hysterical 
diathesis, and the fact that the symptoms come on soon 
after the bite without any period of incubation, will further 
aid in establishing the diagnosis between the false and the 
real disease. 



554 CEKEBRO-SPINAL DISEASES. 

Hydrophobia has "been confounded with tetanus, and 
some writers have regarded it as a modified form of this 
affection. The distinction is, however, so well marked that 
it scarcely seems necessary to dwell upon it. The facts that 
in tetanus the spasms are tonic, while in hydrophobia they 
are clonic ; that in the first-named they are mainly shown 
as regards the jaws and back, while in the latter they radi- 
ate from the throat ; that in tetanus the mind is clear 
throughout, while in hydrophobia more or less mental im- 
plication is always present, will suffice to render any mis- 
take in the diagnosis of the two diseases impossible. 

Prognosis. — There is no authentic instance on record of 
a cure of hydrophobia. Several such have been reported, 
but inquiry has always shown misstatement or error some- 
where. The fact, that the hysterical counterpart has several 
times been regarded as the real disease, is the main support 
for the opinion of some authors that the affection is curable. 

Several years ago Dr. Ligget, 1 of Maryland, reported a 
case of hydrophobia cured by calomel. A careful examina- 
tion of the details of this case excites very grave doubts in 
my mind in regard to its really being an instance of the dis- 
ease in question. 

The subject was a negro-woman who had been bitten 
about two weeks before any symptoms were manifested. 
The dog was lying quietly in the yard, and bit her in the 
great toe as she was teasing him with her foot. The animal 
was at once chained up, and died in two or three days with 
" all the symptoms of rabies canina in its most virulent 
form." It does not appear that the doctor saw the dog, 
and it is very probable that the rigid confinement would 
have caused the animal to exhibit symptoms which would 
easily be mistaken by laymen for those of hydrophobia. 

Again, the period of incubation was unusually short, 
and the symptoms, as detailed by Dr. Ligget, are clearly 

1 Case of Hydrophobia successfully treated with Drachm Doses of Calomel, 
Am. Jour. Med. Science, January, 1860, p. 96. 



HYDROPHOBIA. 555 

not those of hydrophobia. Thus, although he repeatedly 
states that there was inability to swallow liquids, there is no 
distinct mention made of the pathognomonic laryngeal and 
pharyngeal spasms which occur in hydrophobia, and which 
are so frightful in character. The convulsions all appear to 
have been general, and there was a " horror " of water, which 
is not a phenomenon of the true disease. For these reasons 
I am constrained to believe that the disease treated by 
drachm-doses of calomel was in reality one of hysteria which 
assumed the form of hydrophobia. In this opinion I am 
sustained by an eminent medical gentleman residing in Dr. 
Ligget's neighborhood, who, as the latter admits, declared 
the affection to be " a case of that protean disease, hysteria, 
simulating hydrophobia." Calomel has been repeatedly 
tried before and since Dr. Li^et's case, but without effect. 

But, although the prognosis is so hopeless in the devel- 
oped disease, it is much more favorable as regards the super- 
vention of hydrophobia from the bites of rabid animals, for, 
of those bitten by dogs unmistakably affected with the dis- 
ease, not more than one in fifteen become successfully in- 
oculated. This liability differs greatly according to the 
circumstance of the part being covered or not. The wounds 
of the face, neck, or hands, are much more likely to be fol- 
lowed by hydrophobia than those inflicted on the legs or 
feet, where the virus is rubbed off' by the clothing before the 
teeth reach the flesh. The bite of a rabid wolf is more apt 
to be followed by the disease than the bite of a dog, for the 
reason that the first-named generally seizes the throat or 
face. Thus, Trolliet states that at Brives, in France, seven- 
teen persons were bitten by a rabid wolf, of whom ten died 
of hydrophobia ; and, of twenty-three bitten by another, 
thirteen died. On the other hand, Hunter states that on 
one occasion a dog bit twenty persons, of whom only one 
was inoculated. Those first bitten by a rabid animal are 
more liable to have hydrophobia than those bitten subse- 
quently, when the poison is in a measure exhausted. Prob- 



556 CEREBROSPINAL DISEASES. 

ably the most dangerous wounds are those which barely 
penetrate the epidermis, and in which, therefore, the venom 
is not washed away by any flow of blood. 

Morbid Anatomy. — There are no post-mortem appearances 
which can be regarded as peculiar to hydrophobia. The 
brain and its membranes are generally congested, as is also 
the upper part of the spinal cord with its membranes, but 
these changes are met with in other diseases, having no 
affinity by their symptoms with hydrophobia. 

Sometimes the nerves at the wound are found inflamed, 
but this is not a uniform occurrence. The eighth pair has 
been found to present a pinkish appearance in some cases. 
In four cases in which the blood was examined by Schivardi, 1 
infusoria of the genera bacterium, m,onas, vibrio and torula 
were found. 

The fauces, pharynx, larynx, trachea, and lungs, are 
generally found reddened and congested, as much from the 
asphyxia as from any specific influence of the disease. 

Doubtless with our present knowledge of the intimate 
structure of the nervous tissues, and the perfection of our 
means of observation, we shall, ere lorig, be enabled to de- 
tect the nature of the changes which take place in hydro- 
phobia. Now we know nothing of any importance on the 
subject. 

Pathology. — Hydrophobia, if we may judge from the 
symptoms, essentially consists in a hypersesthetic condition 
of the hemispheres, the medulla oblongata, and the upper 
part of the spinal cord. The hallucinations and other men- 
tal phenomena point to the hemispheres, the irregular ac- 
tions of the respiratory muscles, and the heart, together with 
the gastric derangement and pharyngeal convulsions, indi- 
cate the implication of the pneumogastric nerves, and the 
spasms of the larynx point to the origin of the spinal acces- 
sory nerves in the spinal cord. 

The nature of the virus is unknown. It is probably of 

1 Observations nouvelles sur la rage. Besancon, 1868, p. 22. 



HYDROPHOBIA. 557 

the nature of a ferment, but this cannot be regarded as 
satisfactorily proved. 

In 1820, Dr. Marochetti observed, in the Ukraine, that 
during the formative period of hydrophobia small vesicles 
or pustules formed under the tongue, and that, if these were 
opened and cauterized, the further development of the dis- 
ease was prevented. I have never been able to find these 
formations, but they were recognized, two years after Maro- 
chetti published his account, by Magistral, in France. This 
latter opened and cauterized them in the manner recom- 
mended by Marochetti in ten cases, in five of which, never- 
theless, the affection went on to full development, and the 
patients died. I am not aware that any one else has discov- 
ered these pustules. 

For full details relative to hydrophobia as it appears in 
dogs, I must refer the reader to the late Mr. Youatt's excel- 
lent book on canine madness. I may, however, state that it 
is very clearly established that canine rabies is not so fre- 
quent in very hot as it is in temperate or cold weather ; that 
it is not induced by thirst or improper food, or by prevent- 
ing copulation. 

Treatment. — The measures of treatment relate to those 
proper immediately after the infliction of the wound, with 
the view of preventing the development of the disease, and 
those advisable after the affection is unmistakably mani- 
fested. 

Under the first category comes excision, which should be 
performed as soon as possible, and which is probably the 
best of all prophylactics. The operation should not be done 
with a niggardly hand, but every part with which the teeth 
of the animal have come in contact should be removed, as 
well as the tissue into which the poison may have become 
infiltrated. Previous to the operation, in fact as soon as 
the wound has been received, a tight ligature should be 
bound around the limb immediately above the injury, and, 
after the knife has done its work, cupping-glasses should be 



558 CEREBROSPINAL DISEASES. 

applied over the spot till the tissues in the vicinity are 
thoroughly drained of blood. I have performed excision, 
for the wounds received from dogs certainly rabid, six times, 
and always with the effect of preventing hydrophobia. 

Cauterization may be performed instead of excision, and 
is preferred by some practitioners. Mr. Youatt used it with 
over four hundred persons bitten by rabid animals, and 
never unsuccessfully. Four times he employed it on him- 
self, but there is a strong probability that the practice at 
last failed with Mr. Youatt himself, for he committed sui- 
cide while supposed to be suffering from the initial symp- 
toms of hydrophobia. 

He preferred the nitrate of silver as an escharotic. 
Others have made use of the actual cautery, caustic alka- 
lies, the mineral acids, arsenic, chloride of zinc, and carbolic 
acid. I have employed cauterization four times upon per- 
sons bitten by rabid dogs, and always with success. 

Mr. Youatt at one time had faitH that the Scutellaria late- 
riflora, or scullcap, was a preventive. He moistened three 
pieces of tape with the saliva of a rabid dog, and inserted 
them as rowels into the skin of three dogs. To two of these 
he gave Scutellaria combined with belladonna, while the 
third was left to itself. On the twenty-ninth day after the 
inoculation this latter became rabid, while the others, sev- 
eral months afterward, were alive and well. 

Notwithstanding this experience, it would not be justifi- 
able in the physician to neglect performing either excision 
or cauterization as soon as possible after the reception of the 
bite. Even if several weeks or months have elapsed, one or 
the other — preferably excision — should be performed. 

As to the treatment of the fully-developed disease, there 
is nothing in my opinion which has hitherto succeeded in 
arresting its onward course. Cases of cure have been re- 
ported, but, as already stated, they are open to the suspicion 
of not being true instances of the disease. Excessive blood- 
letting has been reported as a successful remedy ; injection 



HYDROPHOBIA. 559 

of warm water into the veins dissipated the paroxysms in a 
case reported by Magendie, the patient, however, dying ; 
and nearly every stimulant, narcotic and sedative, in the 
materia medica, has been used. In the case which I saw 
with Dr. Cook, and which has already been cited, the hy- 
drate of chloral was administered. The effect certainly 
was to mitigate the severity and frequency of the spasms, 
but it was, as Dr. Cook states, given too late in the course 
of the disease to produce any permanently curative result. 
In the present state of our knowledge, I should be more dis- 
posed to rely on the hot-air bath at a temperature of about 
200° Fahr., and the administration of hydrate of chloral in 
large doses frequently repeated, than on any other plan of 
treatment. In Dr. Cook's case the Turkish bath was pro- 
posed, but the parents of the child would not consent to its 
use. 

Before concluding my remarks on this disease, it is prop- 
er to allude to the attempts of Dr. Schivardi, ] of Milan, to 
cure the disease by the primary galvanic current. In one 
case the current was feeble, and was continued for nineteen 
hours. Great improvement ensued ; the oppression disap- 
peared, and the dysphagia was entirely relieved. Through 
some misunderstanding, advantage was not taken of these 
ameliorations, and the patient was allowed to die. 

In the other case, which was one of undoubted hydropho- 
bia, occurring in a girl nine years old, the current from twenty- 
two Daniell's cells was employed. The current was passed 
from the soles of the feet to the forehead for fifty-eight 
hours almost continuously, and the duration of the disease 
prolonged to seven days and seven hours, when the patient 
died. During the last two days there were no hydrophobic 
symptoms. 

Further trials are necessary before the therapeutical 
value of galvanism in hydrophobia can be ascertained. 

1 Observations nouvelles sur la rage. 



CHAPTEE II. 

EPILEPSY. 

Epilepsy, although only a symptom of a morbid condi- 
tion, must for the present be considered as a disease, for the 
reason that we are not able to designate with certainty its 
exact seat, or the nature of the lesion which exists. It is 
characterized by paroxysms of more or less frequency and 
severity, during which consciousness is lost, and which may 
or may not be marked by slight spasm, or partial or general 
convulsions, or mental aberration, or by all of these circum- 
stances collectively. The essential element of the epileptic 
paroxysm is loss of consciousness. Without that there is no 
true, fully-formed epileptic paroxysm. 

Symptoms. — Although in many cases there are no pre- 
cursory phenomena, it often happens that there are indica- 
tions of an approaching attack. These are exceedingly va- 
riable in character and situation. They may consist of 
pain in the head, a sensation of constriction or fulness, ver- 
tigo, noises in the ears, a feeling as if the ears are stopped 
with cotton or water, flashes of light, or sudden blindness, 
illusions or hallucinations of any of the senses — irritability 
of temper, extraordinary cheerfulness, difficulties of speech, 
pains in various parts of the body, especially in the stomach, 
bowels, or ovaries, sensations of numbness or of tingling, or 
of an indescribable character, which begin in an extremity 
or in some other region, and appear to pass rapidly to the 
head — a feeling of constriction in the throat, vomiting, sud- 
den evacuation of the bladder or rectum, erections of the 



EPILEPSY. 561 

penis, with or without the sexual orgasm, and discharge of 
semen, with many others of almost every possible descrip- 
tion. 

The prodromata may precede the attack by a consider- 
able period, but usually are only a few moments in advance 
of it. Indeed, often the interval is so short that they may 
be regarded as a part of the paroxysm. 

The sensations of numbness, or of tingling, or of an 
electric shock, as they are differently described by patients, 
or of pain which originate in some distant part of the body, 
and seem to run rapidly toward the head, are called the 
aura. This aura is usually of the same character in every 
attack of the same patient, though occasionally it varies. 

Delasiauve, 1 of two hundred and sixty-four cases, found 
the paroxysms unannounced in one hundred and one, and 
with precursory phenomena in one hundred and eighty- 
three. The prodromata were immediate in one hundred 
and fifty cases. These he divides into seven categories, as 
follows. It is to be recollected that cases may appear under 
one or more categories, according as the prodromata, as is 
often the case, are met with simultaneously in different 
parts of the body : 

First Series. — Precursory Signs in the Head. — Seven- 
ty-five cases. 

Vertigo, flashes of light 23 

Headache, weight in the head 15 

Heat of face 3 

Various localized sensations 13 

Indefinite sensations 1 

Illusions, hallucinations, and other sensorial aberrations . . 9 

Rotation of the head or of the eyes 5 

Grinding of the teeth, derangement of the motility of the 

tongue 2 

Tendency to sleep 1 

Constriction of the throat 3 

1 Traite de l'Epilepsie — Histoire — Traitement — Medecine Legale, Paris, 
1854, p. 47. 

36 



562 CEREBROSPINAL DISEASES. 

Second Series. — Precursory Signs in the Thorax, — 
Twenty-two cases. 

Oppression of the chest and sense of suffocation -. 9 

Sensation of a ball or of motion in the pectoral region 2 

Shivering sensation of cold or of an aura 5 

Pain or heat 4 

Palpitations, spasms 2 

Third Series. — Precursory Signs in the Abdomen. — 
Thirty-two cases. 

Pain with or without oppression, eructations, vomiting... 13 

Intestinal or uterine colic 3 

Sensation of a ball 3 

Sensation of cold, of a vapor, etc 6 

Stomachal heat 1 

Undefinable sensations 6 

Fourth Series. — Precursory Signs in the Extremities. — 
Ninety-four cases. 

Numbness, contractions, jerkings, retractions, cramps, 

formications, etc 36 

Pain with or without spasms 13 

Tremblings 10 

Aura or phenomena approaching thereto 20 

Undefinable sensations 15 

Fifth Series. — Precursory Signs, consisting of General 
and Undefinable Sensations. — Twenty-two cases. 

General agitation or rotation of the body 8 

Condition of discomfort, fainting, etc 6 

Vague sensations 7 

Moroseness 1 

Sixth Series. — Precursory Signs situated in the Geni- 
tal Organs. — Five cases, such as retraction of the testicles, 
aura starting from the testicles and spermatic cords, sensa- 
tions located in the uterus, etc. 

Seventh Series. — Exceptional Cases. — Desire to defe- 
cate, to urinate, profuse perspiration, etc. 



EPILEPSY. 563 

Of two hundred and eighty-six cases of epilepsy which 
have come under my observation, and in which inquiry was 
made as to the occurrence of prodromata, I ascertained that 
they existed in one hundred and twenty-eight. They did 
not differ in general character from those specified by De- 
lasiauve. 

The Paroxysm. — Great differences are observed in the 
character and severity of the paroxysm. Ordinarily two 
varieties are recognized, the petit mal or slight attack, and 
the grand mal or severe seizure. The first is unattended 
by marked spasm or agitation ; the latter is characterized 
by more or less violent tonic and clonic convulsions. 
These divisions are, however, not regarded as sufficiently 
precise by those who have studied the disease in question 
with care and precision, and more minute classifications of 
the phenomena of the epileptic paroxysm have accordingly 
been made. The one which I have used in my lectures at 
the Bellevue Hospital Medical College for several years 
past is less complex than some others, and embraces all the 
known varieties. It is as follows : 

1. Momentary unconsciousness without marked spasm. 

2. Unconsciousness with evident though local spasm. 

3. Unconsciousness with general tonic and clonic con- 
vulsions. 

4. Irregular or aborted paroxysms. 

Besides these several varieties, there are certain accom- 
paniments, such as mania and paralysis, which will require 
consideration. 

1. Momentary Unconsciousness without Evident Spasm. 
— The patient is perhaps standing, engaged in conversation, 
when a momentary blank in his mental processes occurs. 
It probably does not attract attention ; it is instantaneous, 
disappears, leaving no feeling of discomfort after it, and 
there is an almost immediate continuance of his thoughts 
and speech. 

Or he may be walking in the street when the accession 



564 CEREBROSPINAL DISEASES. 

occurs. He loses himself for an instant, but he continues 
to walk, and does not even stagger. 

In somewhat more severe seizures, if conversing, he stops 
suddenly, stares vacantly but fixedly for a moment, and may 
drop any thing which he has in his hand. 

If walking, his steps are arrested for an instant, he stag- 
gers and would fall but for the quick return of conscious- 
ness. 

Such is the general character of these absences, faints, 
spells, etc., as they are popularly called ; varying, however, 
according to the circumstances of the moment and the con- 
dition of the patient. They frequently exist for a long time 
without the patient paying much attention to them. In a 
gentleman now under my charge they occurred several times 
in the course of the day when walking, riding on horseback, 
sitting quietly in his library, engaged in conversation, or 
eating. He did not consider them of much importance, and 
was surprised when I informed him they were epileptic. 
The continuity of his acts was scarcely interrupted, and 
those about him never noticed that any thing was wrong. 

In the case of a young lady they occur generally at the 
dinner-table. She drops her knife and fork, looks steadily 
to the front, ceases to eat, and in about two seconds resumes 
her occupation with a long-drawn inspiration. Those near 
her observe that her countenance becomes very pale, and 
that she does not hear or see. 

Sometimes these attacks, slight as they are, are fol- 
lowed by pain in the head, vertigo, confusion of ideas, 
numbness, and other evidences of nervous derangement, 
which may last for several hours, and which become more 
pronounced as the epileptic condition becomes more con- 
firmed. 

2. Unconsciousness, with Evident though Local Spasm. — 
In this variety the loss of consciousness is of longer dura- 
tion than in the preceding, and is attended with convulsions 
light in character, but yet apparent to those around. The 



EPILEPSY. 565 

eyes are fixed, as in the first variety, the mind becomes a 
blank, and there is a sensation of vertigo immediately be- 
fore the loss of consciousness, and at the time of its restora- 
tion. The face usually becomes pale first and then red, or 
either of these conditions may occur without the other being 
observed. 

The spasms may be very slight. Sometimes there is 
momentary strabismus, at others retraction of the angles of 
the mouth on one or both sides, rotation of the head or a 
sudden drawing of it backward, or the tongue is thrust for- 
ward and the jaws close on it, inflicting slight injury. 
Again, the chair in which the patient may be sitting is 
pushed back with some force, and the body is bent forward, 
or the muscles of the neck may be affected, and the circula- 
tion thus interrupted in the veins of the neck, causing a dark 
hue of the complexion. 

Sometimes the spasms have an appearance of being 
volitional. A patient under my charge tugs violently at 
his hand ; another walks about the room, but without tak- 
ing any determinate course ; a young lady leaves her chair 
and stands upon another one at some distance from her, and 
another talks all kinds of gibberish. My experience of 
such cases is in accordance with that of Reynolds, 1 to the 
effect that there is no recollection of these acts. These 
attacks are often preceded by prodromata of various kinds. 
The duration never exceeds a minute, and is generally much 
less. 

3. Unconsciousness, with General Tonic and Clonic Con- 
vulsions. — Prodromata may or not be present. In any event 
the paroxysm occurs suddenly. The first circumstance may 
be a cry of a very peculiar character, somewhat resembling 
the bleating of a young lamb. The eyes become fixed, and 
the patient falls to the ground, usually with a bound, as if 
he is shot. The loss of consciousness occurs with the cry or 
the fixedness of the gaze. 

1 System of Medicine, vol. ii., p. 261, Art. Epilepsy. 



566 CEREBROSPINAL DISEASES. 

The muscles are now thrown into a state of tonic con- 
traction ; the respiration is impeded, or altogether arrested ; 
the face, if at first pale, becomes dark ; the pupils are dilated, 
and sensibility is entirely abolished. 

Careful examination of a patient in this stage of the 
paroxysm reveals some important features : the body is rigid, 
but is usually inclined more to one side than the other, in 
the position of a tetanic patient with pleurosthotonos ; the 
eyes are open, and are twisted to one side ; the face is 
likewise more retracted on one side than the other ; the 
sterno-cleido-mastoid muscles, and others of the neck, stand 
out like thick cords ; the carotids throb with force ; the 
veins of the head and neck are turgid with black blood, and 
the pulse is usually weak and fluttering. 

After this stage has lasted for a period varying from two 
or three seconds to half a minute, a great change ensues. 
The unconsciousness continues, but the general tonic spasm 
relaxes, and clonic convulsions take its place. These are 
general, but are ordinarily more strongly marked on one 
side of the body than on "the other. The muscles of the 
face are alternately contracted and relaxed ; the tongue is 
often thrust between the teeth, and, the jaws being closed 
upon it, it is terribly injured ; the upper and lower extremi- 
ties are in a state of continued agitation, and the contents 
of the bladder, rectum, and vesiculse seminales, may be 
evacuated. 

The respiration is forced and irregular, froth issues from 
the mouth, and, if the tongue has been bitten, it is colored 
with blood. 

The muscles of the neck do not relax to any considera- 
ble extent ; consequently the veins remain distended, and 
the face continues to be livid. The pupils oscillate, some- 
times being dilated and then contracted, or one may be con- 
tracted and the other dilated. The heart beats with great 
irregularity, both as to force and frequency. 

This stage may last from a few seconds to five minutes. 



EPILEPSY. 5^7 

Cases of longer duration are on record, but they are exceed- 
ingly rare. 

The third stage of the paroxysm is characterized by the 
gradual return of consciousness. The patient, though still 
somewhat convulsed, looks around him and gives evidence 
of returning sensibility in other ways. The pupils cease 
their disorderly movements, and are contracted ; the respi- 
ration and pulse become more regular, and he may even 
attempt to speak. It often happens that little spots of ex- 
travasated blood make their appearance under the skin of 
the forehead, eyelids, cheeks, and sometimes on the neck 
and breast. These disappear in a few days. 

The duration of this stage is from a few seconds to four 
or five minutes, and it is often so slightly marked as to 
escape observation. 

With the cessation of the convulsive movements the 
stage of stupor usually supervenes, though it may be en- 
tirely absent, especially in old cases of epilepsy. During 
this stage there are sometimes clonic spasms of no great 
degree of severity. It may last a few minutes or several 
hours. When the patient arouses from it, he generally has 
headache, and a feeling of lassitude and soreness of the mus- 
cles, from the violent contractions they have undergone. 

4. Irregular or Aborted Paroxysms. — In these it may 
happen that the loss of consciousness is not complete, or 
that the patient has convulsive movements partial in char- 
acter and accompanied simply by vertigo, or he may have 
unconsciousness lasting for an hour or more, during which 
he performs automatic acts, of which he has no recollec- 
tion, but which are not accompanied by any movements 
that can properly be called spasmodic. 

In his interesting lecture on " Apoplectiform Cerebral 
Congestion," Trousseau * cites a number of cases which were 
clearly instances of irregular or aborted epileptic paroxysms. 
Among them is that of a magistrate whose sister was an 

1 Op. cit., Bazire's Translation, p. 19, et seq. 



568 CEKEBRO-SPINAL DISEASES. 

inmate of a lunatic asylum. He was president of a provin- 
cial tribunal. One day he got up all of a sudden, muttered 
a few unintelligible words, and went to the deliberating- 
room. The usher followed him, and saw him make water 
in a corner. A few minutes afterward he returned to his 
seat, and again listened with intelligence and attention to 
the pleadings momentarily interrupted. He had no recol- 
lection of the incredibly incongruous act he had committed. 
This gentleman belonged to a literary society, which held 
its meetings at the Hotel de Yille, of Paris. At one of 
these, during the discussion of an important historical point, 
he was seized with vertigo. He ran quickly down to the 
Place de Hotel de Yille, and walked about for a few min- 
utes on the quays, avoiding with success both carriages and 
the passers-by. On recovering himself he perceived that he 
had come out without his great-coat and his hat. He there- 
fore returned to the meeting, and resumed with a perfectly- 
lucid mind the historical discussion in which he had already 
taken a very active part. He retained no recollection what- 
ever of what had occurred between the beginning of the at- 
tack and the moment he recovered himself. 

Many cases similar to these might be cited from other 
authors. From a number which have happened in my own 
experience I adduce the following : 

J. H. consulted me for epilepsy in the summer of 1869. 
His ordinary attacks were of the fully-developed form ; but 
upon two occasions they were different from any with which 
he had previously been affected. On one of these, while 
overlooking some workmen, he was observed to put his 
hand to his head, and then suddenly to run toward a fence, 
which he speedily climbed. Jumping down into the back- 
yard of the adjoining house, he seized a stick of wood near 
by, and made a furious onslaught on the door and windows. 
While thus engaged he was seized by several men, and for- 
cibly held notwithstanding his struggles. While thus be- 
ing restrained he recovered his consciousness, but had no 



EPILEPSY. 569 

recollection of any thing which had taken place after he had 
put his hand to his head, which action he said was due to 
severe pain with vertigo. The duration of the attack was 
not over three minutes. 

On the other occasion he was seized with pain and ver- 
tigo while engaged in paying a bill at a coal-yard. He 
rushed into the street, and began to turn rapidly round. 
He was seized and held till he recovered his consciousness. 
This attack lasted about four minutes. 

Subsequently he had a similar paroxysm in my consult- 
ing-room. His face suddenly became very pale, his eyes 
were fixed, and his pupils oscillated. Suddenly he rose 
from the chair, grasped the mantel-piece for an instant, and 
then rushed violently around the room, throwing his arms 
about, and uttering a peculiar inarticulate cry. I made no 
attempt to restrain him, and in about two minutes he be- 
came calm. During the whole paroxysm his face was pale, 
and at its close the pupils were dilated. He had no recol- 
lection of any thing which had occurred after he rose from 
the chair, but was conscious then of vertigo. 

Another case is that of a girl brought to my clinic at the 
Bellevue Hospital Medical College during the summer of 
1869. She had been severely injured in the skull by a fall 
against a mass of old iron. Necrosis subsequently ensued, 
and several large pieces of the external table were exfoliated. 
While before the class, she started to her feet, and walked 
several times around the closed area. She was unconscious, 
and to all appearance insensible. When the paroxysm was 
over, she returned to her seat. The duration did not ex- 
ceed a minute, and there was no excitement or delirium. 

Cases such as these are sometimes classed as epileptic 
mania, but it is better to restrict this term to those parox- 
ysms of mental aberration which come on after a true epi- 
leptic attack. 

Epileptic fits may take place at night during sleep, and 
the patient be unaware of their existence, unless he in- 



570 CEREBROSPINAL DISEASES. 

flicts some injury on himself, such as biting his tongue, or 
is told of their occurrence by persons who may be in the 
same room with him. In two hundred and six of my cases 
the period of access is noted, and of these forty-seven were 
nocturnal, and one hundred and fifty-nine diurnal. 

In the intervals between the paroxysms epileptics often 
exhibit certain evidences of disordered mental, sensorial, 
and motor functions. Thus, as regards the first category, 
the memory may be impaired, and there may be diminished 
mental power. There are, however, many exceptions to 
this rule ; and, even where there have been a great many at- 
tacks, the mind may preserve its normal degree of integrity. 
As Reynolds remarks, in regard to this point : " A patient 
may be epileptic and a lunatic ; he may be epileptic and 
asthmatic, but there are some epileptics whose minds are as 
healthy as their lungs ; and, so far as the natural history of 
epilepsy is concerned, it is a mistake to derive it from com- 
plicated cases." Still, in the majority of cases, it will be 
found that the mind sooner or later becomes involved, and 
it sometimes happens that a single attack causes marked 
intellectual deterioration. 

Derangements of sensibility are common from the be- 
ginning. Headache, a feeling of constriction around the 
forehead, and occasionally a pain at the back of the head, 
are noticed. Yertigo is also frequently present, as are also 
sensations of numbness in different parts of the body. The 
pupils are almost invariably dilated. 

The motor power of the patient is generally weakened 
without there being any decided paralysis. Twitchings of 
the muscles are not uncommon, and there is often a general 
excitability of the reflex faculty of the spinal cord, by which 
jerkings of the limbs are produced by slight excitations. 

In examining with the ophthalmoscope the fundus of the 
eye in epileptics, we can often detect evidences either of 
cerebral congestion or of anaemia, and thus obtain valuable 
indications for treatment. During the last two years, in my 



EPILEPSY. 571 

lectures at the Bellevue Hospital Medical College, I have 
constantly insisted on this point, and in my cliniques have 
exhibited several cases in which I had been guided to suc- 
cessful treatment by the ophthalmoscope. Drs. Kostle and 
Niemetshek, 1 of Prague, consider that the brain in epilep- 
tics is always anaemic, and that this condition is invariably 
found by ophthalmoscopic examination. According to these 
observers, the venous pulse is produced when the eye is 
made anaemic, and they assert that the retina is anaemic, 
and that there is consequently venous pulsation in every 
case of epilepsy. That this opinion is erroneous, both as to 
facts and inferences, I am very sure. Yenous pulsation, so 
far from being indicative of anaemia, really shows the ex- 
istence of the very opposite condition. My observations 
are, however, to the effect that venous pulsation is present 
in many cases of epilepsy, and that it accompanies dilata- 
tion of the veins. 

There is no invariable rule as regards the occurrence of 
any particular form of epilepsy in the same person. It thus 
often happens that all the varieties of paroxysm mentioned, 
except the irregular or aborted form, which is more rare, 
are met with in one individual. The more severe form 
may occur at longer intervals, and the milder forms more 
frequently. As regards frequency, there are great varia- 
tions. Some patients go a year or more without attacks, 
while others have several every day. It generally happens 
that the intervals become progressively shorter. As a rule, 
attacks of the milder forms are more frequent than the fully- 
developed paroxysm, and attacks of the latter are milder, as 
they are more frequent. 

Mania is sometimes a consequence of epilepsy. It 
comes on after the attack, and is rarely of more than a 
few minutes' duration. Those cases in which it precedes 
the paroxysm, and lasts several hours or days, are cases of 

1 Prager Vierteljahrschrift, H. 106, 107, 1870, and Quarterly Journal op 
Psychological Medicine, January, 1871, p. 128. 



572 CEREBROSPINAL DISEASES. 

mania conjoined with epilepsy — a combination which, as 
every insane asylum shows, is not uncommon. The mania 
of epilepsy is usually of a very exalted character, and dur- 
ing its existence the subject may commit homicide or other 
crimes. 

The mental state of epilepsy has been well studied by 
Falret, 1 and a very interesting case has been recently re- 
ported by Dr. Thorne, 3 in a paper entitled " Masked Epi- 
lepsy." In this instance the patient often returned to his 
home without being able to give any account of what he 
had been doing or where he had been. During these at- 
tacks he was frequently the subject of that form of mental 
derangement called kleptomania. Generally they ensued 
on paroxysms either of the grand or petit mal, but some- 
times they were substituted for the regular seizures. He 
had no recollection of what transpired during the attacks. 
Sometimes he was furiously excited in them, and would en- 
deavor to injure himself and others in his blind rage. 

The medico-legal relations of epilepsy do not, however, 
come within the scope of the present treatise. 

Paralysis may follow epilepsy, but, unless the case is 
complicated with some organic difficulty of the brain or 
spinal cord, the loss of power is temporary. 

Causes. — Among the predisposing causes of epilepsy he- 
reditary tendency stands first. Reynolds 3 states that, in 
about one-third of the cases under his observation, heredi- 
tary taint existed. He does not, by this statement, how- 
ever, mean to assert that epilepsy existed in one-third of 
the parents, but that some disease of the nervous system, 
more or less closely allied to epilepsy, was present in 
either the parents, the grandparents, the aunts, uncles, 
brothers, or sisters. Only twelve per cent, of his cases 

1 De l'Etat Mental des Epileptiques. Archiv. Gen. de Med., Decembre, 1860, 
et Avril, et Octobre, 1861. 

2 St. Bartholomew's Hospital Reports, 1870. 

3 Op. cit., p. 253. 



EPILEPSY. 



573 



gave a distinct history of epilepsy in either branch of their 
families. 

Herpin, 1 of sixty-eight cases, found that ten were de- 
scended from epileptic ancestors. 

Delasiauve, 3 of three hundred cases, found decided evi- 
dence of hereditary tendency in thirty-three. In one 
hundred and sixty-seven there were no data, and in one 
hundred and twenty hereditary taint was denied. Of the 
thirty-three cases, live were descended from epileptic an- 
cestors. 

Sieveking 3 found that hereditary influence was present 
in 11.1 per cent, of his cases. 

In my own experience I have notes in regard to this 
point in one hundred and seventy-one cases. Of these, 
twenty-one had epileptic fathers, mothers, grandparents, 
uncles, aunts, brothers, or sisters, and twenty-four had rela- 
tives insane, hysterical, cataleptic, affected with severe neu- 
ralgia, or of remarkably irritable nervous systems. 

Sex does not appear to exercise any appreciable influence 
as a predisposing cause. Of two hundred and six cases 
noted by myself, one hundred and ten were in males and 
ninety-six in females. Other authors have, however, had 
directly opposite experience. 

Age has a very decided influence. Reynolds gives the 
following table of one hundred and seventy-two cases col- 
lected by himself: 



Age at Commencement 

Under 10 years 

Between 10 and 20 years 

Between 20 and 44 years 

Over 45 years 

Total 



Males. 



Females. 



Total. 



10 

66 

25 

1 



102 



9 
40 
20 

1 



70 



19 

106 

45 

2 



172 



1 Du Pronostic et du Traitement Curatif de l'Epilepsie, Paris, 1852, p. 325. 

2 Op. cit., p. 189. 3 On Epilepsy, etc., London, 1858, p. 74. 



574 CEREBRO-SPINAL DISEASES. 

My own cases were as follows : 



Age at Commencement. 


Males. 


Females. 


Total. 


Under 1 years 


12 

62 

29 

1 


13 

45 

32 

6 


25 


Between 10 and 20 years 


10*7 


Between 20 and 45 years 


61 


Over 45 years 


13 






Total 


110 


96 


206 



It is thus seen that the period of life between ten and 
twenty years is that at which epilepsy is most apt to occur. 
The experience of others is to the same effect. The influ- 
ence of temperament has been thought important by some 
writers. But, aside from the different opinions entertained 
relative to the characteristics of the temperaments, it is by 
no means established that, even when strictly defined, tem- 
perament exercises any effect as a predisposing cause. I 
have no accurate records on this point, though so far as my 
memory serves me I have observed no marked predominance 
of epileptics with any temperament. 

The exciting causes may very properly be classified as 
psychical, eccentric, general organic changes, and physical 
influences. Relative to the influences of these causes, Rey- 
nolds gives the following table : 

Nature of Cause. No. of Cases. 
I. Psychical — such as fright, grief, worry, overwork . . 29 
II. Eccentric irritation — dentition, indigestion, vene- 
real excesses, dysentery, etc 16 

III. General organic changes — fatigue, pregnancy, mis- 

carriages, rheumatic fever, scarlet fever, diph- 
theria, pneumonia 9 

IV. Physical influences — blows on head, falls, insola- 

tion, cuts 9 

In my own cases no cause could be assigned in one hun- 
dred and four. The remaining one hundred and two cases 
were, according to the evidence received, caused as follows : 



EPILEPSY. 575 

Fright 5 

Anxiety 4 

Grief 6 

Over-mental exertion 17 

Dentition 11 

Indigestion ... 11 

Venereal excesses 15 

Menstrual derangement 10 

Blows on head 7 

Falls 3 

Sunstroke 2 

Scarlet fever 2 

Measles 1 

Diphtheria 2 

Pregnancy 3 

Syphilis 3 

102 

Diagnosis. — The diagnosis of epilepsy presents no diffi- 
culties to the careful observer. It may, however, be con- 
founded with several conditions, the principal of which are 
cerebral congestion, cerebral haemorrhage, hysteria, the 
convulsions of infancy and of Bright's disease, poisoning 
by opium and alcohol, syncope, and with the convulsions 
of epileptiform character which occur in the course of cer- 
tain organic diseases of the brain. 

The diagnosis from cerebral congestion and cerebral 
haemorrhage has already been given in the chapters treat- 
ing of these affections. In hysteria, the convulsions, which 
are sometimes epileptiform in character, are preceded or ac- 
companied by other evidences of the hysterical state. Con- 
sciousness is rarely entirely lost, the tongue is not bitten, 
and there is no subsequent stage of stupor. 

The convulsions of infancy not epileptic are not repeat- 
ed but from a readily-ascertained exciting cause, such as 
dentition, indigestion, falls, etc. So far as the paroxysm is 
concerned, I know of no specific points of difference ; but it 
must be recollected that the paroxysm is not the only fea- 



576 CEREBROSPINAL DISEASES. 

ture of epilepsy, and that it is the only feature of infantile 
convulsions. These latter may pass into epilepsy ; but, if 
they do not, I have never been able to find a single case in 
my experience in which epilepsy ensuing in adult life has 
been preceded by the ordinary infantile convulsions. In 
Bright's disease, though the convulsions may be epilepti- 
form in character, coma is the principal feature, and the 
history of the case will further serve to render the diagnosis, 
exact. The same remarks are applicable to poisoning by 
opium and alcohol. 

From syncope epilepsy is distinguished by the facts that 
the loss of consciousness is sudden and complete, that the 
pulse is not feeble, and that recovery is rapid. These re- 
marks apply to the milder attacks without convulsions. 
From the more severe forms of the paroxysm the distinction 
is too obvious to require amplification. 

In organic diseases of the brain, such as tumors, soften- 
ing, sclerosis, etc., the accompanying symptoms, pain, pa- 
ralysis, tremor, imbecility, difficulties of speech, and de- 
rangements of the special senses, will serve to distinguish 
them from epilepsy. 

Epilepsy is often assumed by designing persons for pur- 
poses of fraud. In such cases the pretender usually overacts 
his part ; his sensibility is not abolished, as may readily be 
ascertained by putting the end of the finger on the conjunc- 
tiva, and the size of the pupils is not altered. 

Prognosis. — The prognosis depends to a great extent on 
the duration of the disease. Eecent cases can often be 
cured, but those which have lasted for several years are 
rarely brought to a favorable termination. Among the 
other unfavorable elements are the existence of hereditary 
influence, the beginning of the disease late in life, the pres- 
ence of material mental weakness, and the existence of long 
intervals between the attacks. 

As regards the probability of the supervention of any 
form of intellectual derangement or debility, the most im- 



EPILEPSY. 577 

portant ascertained point is that the mild paroxysms unat- 
tended by convulsions are more productive of mental decay 
than the severe form of seizure. The occurrence of the first 
attack late in life is likewise a predisponent to dementia. 

I have never, in my own experience, known death to 
take place during a paroxysm of true epilepsy ; such cases, 
however, do occur. Usually, however, some intercurrent 
affection carries the patient off, though even with this lia- 
bility life is sometimes astonishingly prolonged. I am ac- 
quainted with the case of a lady who is now sixty-five 
years of age, and who, since her tenth year, has averaged 
six paroxysms daily, all of the severest character. Her 
mind is almost entirely gone, but physically her health is 
excellent, and to all appearance she may live twenty years 
longer. 

I am not aware of any exact observations tending to 
show the relative danger to life of attacks of the milder and 
severer forms ; though it is reasonable to suppose that, so 
far as regards the occurrence of death during the paroxysm, 
the convulsive form is more fatal. 

. Morbid Anatomy. — In post-mortem examinations of per- 
sons dying epileptic, abnormal conditions are found in every 
part of the brain and spinal cord. Some of these lesions 
are undoubtedly secondary, others unessential, while those 
which may be considered primary vary in their seat and 
character. In a great many cases, perhaps the majority, no 
lesions, are discoverable. 

No one has been more thorough in the search for the 
essential cause of epilepsy than Schroeder van der Kolk ; 1 
though his observations can scarcely be regarded as yielding 
conclusive results, they serve to show, when taken in connec- 
tion with the pathology of the disease in question, that its 
seat is mainly in the medulla oblongata, with secondary im- 

1 On the Minute Structure and Functions of the Medulla Oblongata, and on 
the Proximate Causes and Rational Treatment of Epilepsy. New Sydenham 
Soc. Translation, London, 1859. 
37 



578 CEREBRO-SPINAL DISEASES. 

plication of other parts of the cerebro-spinal nervous system. 
Oftentimes, in accordance with other pathologists, he found 
nothing to account for the affection, but at others he found 
hardening and contraction of the medulla oblongata, and 
again degeneration of the brain either as a consequence or 
cause of the disease. Microscopical examination sometimes 
showed him the medulla indurated, sometimes softened, and, 
as a constant phenomenon, " whether the patient died in or 
out of the fit, great redness and vascular tension in the 
fourth ventricle, penetrating into the medulla oblongata 
sometimes to a considerable depth." These appearances 
were due to enlargement of the blood-vessels, as was shown 
by microscopical measurements. It is probable, however, 
as Schroeder van der Kolk asserts, that the lesions in ques- 
tion are the results, and not the causes, of the paroxysms. 
Still they suffice to indicate the main seat of the disease to 
be the medulla oblongata. 

Other observers have not so uniformly found this en- 
largement of the blood-vessels of the medulla. In three 
cases of death occurring in epileptics, in which I have had 
the opportunity of making post-mortem examinations, they 
certainly did not exist, nor was there any other lesion de- 
tected by the most careful microscopical exploration. In 
one other case the vessels of the medulla oblongata were en- 
larged, and there was amyloid degeneration of the pituitary 
body. 

Pathology. — The points which may be considered as to 
some extent established relative to the pathology of epilepsy 
are briefly summarized as follows by Reynolds : ' 

" 1. That the seat of primary derangement is the me- 
dulla oblongata and upper portion of the spinal cord. 

" 2. That the derangement consists in an increased and 
perverted readiness of action in these organs, the result of 

1 Op. cit., p. 275, and more fully stated in his Treatise on Epilepsy, its 
Symptoms, Treatment, and Relations to other Chronic Convulsive Diseases, 
London, 1861, chapter v., p. 238. 



EPILEPSY. 579 

such action being the induction of spasm in the contractile 
fibres of the vessels supplying the brain, and in those of the 
muscles of the face, pharynx, larynx, respiratory apparatus, 
and limbs generally. 

" By contraction of the vessels the brain is deprived of 
blood, and consciousness is arrested ; the face is or may be 
deprived of blood, and there is pallor • by contraction of the 
vessels which have been mentioned, there is arrest of respi- 
ration, the chest walls are fixed, and the other phenomena 
of the first stage of the attack are brought about. 

" 3. That the arrest of breathing leads to the special 
convulsions of asphyxia, and that the amount of these is in 
direct proportion to the perfection and continuance of the 
asphyxia. 

"4. That the subsequent phenomena are those of poi- 
soned blood, i. e., of blood poisoned by the retention of car- 
bonic acid, and altered by the absence of a due amount of 
oxygen. 

" 5. That the primary nutrition-change, which is the 
starting-point of epilepsy, may exist alone, and epilepsy be 
an idiopathic disease, i. e., a morbus per se. 

" 6. That this change may be transmitted hereditarily. 

" 7. That it may be induced by conditions acting upon 
the nervous centres directly, such as mechanical injuries, 
overwork, insolation, emotional disturbances, excessive ve- 
nery, etc. 

" 8. That the nutrition-changes of epilepsy may be a 
part of some general metamorphosis, such as that present in 
the several cachexias — rheumatism, gout, syphilis, scrofula, 
and the like. 

" 9. That it may be induced by some unknown circum- 
stances determining a relative excess of change in the me- 
dulla during the general excess and perversion of organic 
change occurring at the periods of puberty, of pregnancy, 
and of dentition. 

" 10. That it may be due to diseased action, extending 



580 CEREBROSPINAL DISEASES. 

from contiguous portions of the nervous centres or their 
appendages. 

" 11. That the so-called epileptic aura is a condition of 
sensation or of motion, dependent upon some change in the 
central nervous system, and is, like the paroxysm, a pe- 
ripheral expression of the disease, and not its cause." 

While admitting the correctness of these conclusions, 
they do not, in my opinion, tell the whole story of the the- 
ory of epilepsy. In very many memoirs Dr. Brown-Sequard 
has pointed out the dependence of the affection upon inju- 
ries of the upper part of the spinal cord, and upon irrita- 
tions existing in various parts of the body. His researches, 
and facts observed every day by physicians who see many 
cases of epilepsy, show very conclusively that the starting- 
point is often in the sympathetic nerve — the nerve by which 
the calibre of the blood-vessels is regulated. 

Neither can I accept the view that the first intra-cranial 
condition producing a paroxysm is in all cases spasm of 
the blood-vessels and the consequent deprivation of the 
blood-supply to the brain. On the contrary, I am very sure 
that the primary state is often paralysis of the cerebral 
blood-vessels and resulting hyperaemia. By this condition 
the medulla oblongata is thrown into a state of over-excita- 
tion, giving rise to convulsions, and consciousness is lost 
from the fact that the hemispheres participate. That con- 
vulsions epileptiform in character may be produced both by 
cerebral anaemia and cerebral hyperemia, when either con- 
dition involves the medulla oblongata, is a fact which ex- 
periment has abundantly established, and that loss of con- 
sciousness follows either condition involving the hemispheres 
is equally certain. We have, consequently, two kinds of 
epilepsy — the one due to anaemia, the other to congestion — 
and it is to this fact that is due the circumstance that some- 
times the paroxysms are prevented by measures which tend 
to increase the amount of blood in the brain, and at others 
by remedies which exercise a contrary influence. The ex- 



EPILEPSY. 581 

istence of the two species of epilepsy is likewise shown by 
ophthalmoscopic examination — a point upon which I have 
already insisted. 

During natural sleep the amount of blood is, as I have 
elsewhere shown, decreased from the quantity which circu- 
lates in the cerebral blood-vessels during wakefulness. Epi- 
lepsy occurring during sleep is therefore of the anaemic va- 
riety. But it often happens that sleep passes gradually into 
stupor, from the fact that causes tending to increase the flow 
of blood to the brain, or to arrest its passage from this or- 
gan, are in operation. In such cases epilepsy of the conges- 
tive variety may be induced. 

In those cases in which the tongue is bitten the medulla 
oblongata is probably always in a condition of hyperemia ; 
and this state, as Schroeder van der Kolk has very conclu- 
sively shown, is mainly in the course of the roots of the 
hypoglossal nerve. The intermissions between the attacks 
are ingeniously explained by the same able observer, by 
likening the cells of the medulla oblongata to Ley den jars 
charged with electricity, or to the electrical organs of the 
conger-eel and torpedo. After being discharged, time is 
necessary for the reaccumulation of sufficient electricity to 
discharge them again ; and, when the cells of the medulla 
have once discharged themselves in an epileptic convulsion, 
a period must elapse before another access can take place. 

The foregoing remarks apply in the main to that form 
of epileptic seizure characterized by convulsion. In the 
imperfectly-developed attacks the implication of the me- 
dulla oblongata must be very slight, the hemispheres being 
the organs mainly affected, and the condition being some- 
times anaemic, at others hyperaemic. 

It must not be supposed, from what has been said, that 
simple cerebral anaemia and simple cerebral congestion, at- 
tended with epileptiform convulsions, are identical with the 
anaemia and congestion of epilepsy. This disease is cerebral 
anaemia or congestion with another element, the exact na- 



582 CEREBRO-SPINAL DISEASES. 

ture of which we do not understand, but which is certainly 
of such a character as to constitute the main differential 
point between epilepsy and any other affection. 

Treatment. — To attempt the consideration of all the 
means which have been employed in the treatment of epi- 
lepsy would be a hopeless task. Their mere mention would 
require several pages of this treatise. I shall therefore con- 
tent myself with detailing the methods which I have found 
most useful. 

First among remedies are the bromides of potassium, 
sodium, or lithium. The first should be given to adults in 
doses of at least fifteen grains three times a day, and is gen- 
erally required in larger quantity. It acts very much bet- 
ter when largely diluted with water. A saturated solution 
contains about thirty grains to the drachm, and a half a tea- 
spoonful or more should be mixed in at least a gill of water. 
Latterly I have used the bromide of sodium in doses a little 
smaller. It is, I think, more readily assimilated, and is less 
apt to produce gastric irritation, but, in other respects, its 
action is similar to that of the corresponding potassium 
salt. The bromide of lithium has a more immediate ac- 
tion ; but I have not succeeded in obtaining any continuous 
effects from it in epilepsy which I could not derive from the 
potassium or sodium salt, and its great cost is a bar to its 
lengthened administration. 

It must be clearly understood that the bromide is to 
be taken for at least a year, and in most cases longer, before 
its administration is stopped. After the initial dose has 
been given for about two months, if there are no symptoms 
indicating bromism, I increase the doses by one-half, if 
there has been no paroxysm in the mean time. If there 
have been paroxysms, I increase by one-half after each 
paroxysm until they are arrested, or until I am convinced 
that the bromide is inefficacious or injurious. In the case 
of a gentleman from Cincinnati, I began with twenty grains 
three times a day ; he still had attacks ; I increased the 



EPILEPSY. 583 

doses to thirty grains, with little or no effect ; then to forty- 
five grains, and, as he still had an occasional fit, I increased 
the doses to four a day. He therefore took one hundred 
and eighty grains a day, and then his paroxysms ceased. I 
have never given beyond this quantity, and, if it had not 
proved successful, I should have abandoned the idea of ar- 
resting the disease with the bromide of potassium. The 
gentleman in question has had but one attack during the 
last three years, and this was the result of his suddenly 
omitting to take his medicine for several days. When he 
was thoroughly under the influence of the drug, I reduced 
the doses, and he now takes thirty grains three times a day. 
He had been previously treated with smaller doses, with 
good effect at first, but for some time before he came under 
my care they had lost their influence. 

"With either bromide I usually conjoin the oxide of zinc 
in doses of two grains three times a day. In several cases 
in which large doses of the bromide had failed, the parox- 
ysms were arrested when the oxide of zinc was given in 
addition. In one case in which the bromide aggravated the 
disease, and in which the oxide of zinc was ineffectual, the 
patient, a young lady of this city, was cured after taking the 
lactate of zinc in doses of four grains three times a day. In 
no other case has this salt produced the least effect in my 
hands. 

I rarely continue the oxide of zinc for a longer period 
than two months, for the reason that it appears, after that 
period, to produce a cachexia, manifested by loss of appe- 
tite, anaemia, and general debility. 

With the bromide I generally administer strychnia in 
doses of the thirty-second to the twenty-fourth of a grain, 
for the purposes of a tonic, and for counteracting, to some 
extent, the debilitation produced by the bromide. 

When the opportunity affords, I always make use of the 
con stant galvanic current, applying it to the brain and sym- 
pathetic nerve. There should ordinarily be three seances a 



584 CEREBROSPINAL DISEASES. 

week, each of about ten minutes. For one-third of this 
time I pass the current antero-posteriorly, one pole being 
placed on the back of the neck, and the other on the fore- 
head ; for another third, one pole is placed on each mastoid 
process, and for the other, one on the sympathetic nerve in 
the neck, and the other on the spinal column at about the 
first dorsal vertebra. The current should be derived from 
ten or fifteen Smee's or Daniell's elements. 

Occasionally I have employed setons — a skein of silk, or 
a piece of thin india-rubber, being passed through the skin 
of the nucha. 

The results obtained are shown in detail in the following 
synopsis : 

One or other of the bromides was given in two hundred 
and eighty-six cases. 

The condition of the patient was aggravated in nineteen 
cases ; all were of the nocturnal form, and one has been re- 
ported in detail. 1 

No appreciable effect was produced from doses of one 
hundred and twenty grains a day in twenty cases, and the 
administration was stopped. Eleven of these were noc- 
turnal. 

No appreciable effect from doses of one hundred and 
sixty grains a day in four cases, and the medicine was ac- 
cordingly discontinued. 

The severity and frequency of the fits were diminished, 
but they were not arrested, with doses ranging from forty- 
five to one hundred and sixty grains daily, in one hundred 
and fifty- two cases. 

No fits occurred while the bromide was being taken, in 
ninety-one cases. Of these latter the bromide has been 
stopped for over six months, and there has been no return 
of the fits in sixty -five cases. 

In the remaining twenty-six cases the bromide has to 

1 A Case of Epilepsy due to Cerebral Anaemia, Journal op Psychological 
Medicine, April, 1868, p. 368. 



EPILEPSY. 585 

be continued in order to prevent the recurrence of the par- 
oxysms. 

Of the two hundred and eighty-six cases in which the 
bromide was administered, the seizures were therefore en- 
tirely arrested or lessened in frequency or severity in two 
hundred and forty-three, while in forty-three it was either 
positively injurious or without effect. 

Of the two hundred and forty-three completely or par- 
tially successful cases, the bromide was combined with oxide 
of zinc in seventy-four. 

Of these seventy-four cases, fifty-two were, of the sixty- 
five, thoroughly successful cases. 

The primary galvanic current was used to the brain, me- 
dulla oblongata, spinal cord, and sympathetic nerve, in one 
hundred and thirty cases. 

Of these one hundred and thirty cases, fifty-nine were 
among the entirely successful cases. 

Setons were employed in fifteen cases. 

Of these fifteen cases, three were among the completely 
successful cases. 

These data go to show that the treatment which in my 
hands has been productive of the best results, is that in 
which one of the bromides, oxide of zinc, and the primary 
galvanic current, were conjointly used. 

In forty-three cases the bromide was productive either 
of an injurious effect, or was without influence. The ma- 
jority of these were nocturnal. 

Five of these unsuccessful cases were subsequently treat- 
ed with other remedies. One was cured by the lactate of 
zinc; one by changing the time for sleeping, and by the 
administration of iron, quinine, and porter; and three by 
strychnia, in small doses, as recommended by Mr. Tyrrel. 

Of the one hundred and fifty-two cases in which the 
bromide was only partially successful, four were cured by 
strychnia. 

I have not considered a case as fully cured till the pa- 



586 CEREBRO-SPINAL DISEASES. 

tient has been for six months without a fit after ceasing to 
take medicine. In all, out of the two hundred and eighty-six 
cases cited, seventy-four were of this category. Thus far 
there have been, so far as my knowledge extends, but seven 
relapses. In two of these the fits recurred ten months after 
ceasing to take the medicines ; in two fourteen months ; and 
in three fifteen months. In all of these the medicines were 
at once resumed, and they are now under treatment. None 
of these relapses have as yet been from the strychnia treat- 
ment. My experience with this agent, though thus far sat- 
isfactory, is not yet sufficiently extensive to warrant the 
expression of a decided opinion as to its value when com- 
pared with the bromides. I am inclined, however, to think 
that it is more efficacious in the nocturnal form of epilepsy 
than in the diurnal, and in the non-convulsive rather than 
in the convulsive varieties. A point connected with the 
treatment with the bromides must not be overlooked, and 
that is the cachexia which so generally attends their admin- 
istration in large doses. In a memoir, 1 published over two 
years ago, and which has been cited in another connection, 
I brought forward several cases in which this cachexia had 
been produced. Greatly-increased experience has confirmed 
the opinion there expressed, that it never causes any perma- 
nently ill effects, though I have frequently seen great consti- 
tutional disturbance induced. In three cases large car- 
buncles were caused, and in a few I have been obliged to 
suspend for a time the administration of the medicine. 

I am very sure that bromic cachexia is favorable to the 
eradication of the epileptic tendency, and I therefore endeav- 
or to produce it as soon as possible. It appears in many 
cases to alter the whole organism of the patient to such an 
extent as to leave him, when it disappears, with his nutritive 
processes and his proclivities so modified that epilepsy is no 
longer possible. The physician will require all his firmness 

1 On Some of the Effects of the Bromide of Potassium when administered 
in Large Doses, Journal of Psychological Medicine, January, 1869, p. 46. 



EPILEPSY. 587 

and courage to persevere in those cases in which the bromism 
is extreme. But he should not yield unless the phenomena 
are so intense, and the strength of the patient so reduced, as 
to excite his gravest apprehensions. 

Five cases of epileptiform seizures, not included among 
the cases cited, have been under my charge, in which there 
was a decided syphilitic taint present. In these the bro- 
mide of potassium was not administered to any considerable 
extent, reliance being mainly placed on the iodide, given in 
gradually-increased doses. In three cases the result is un- 
known ; in two the treatment was entirely successful. 

My experience with trephining is limited to one case, 
in which the operation was performed by my friend Dr. 
Van Buren. It was unsuccessful, although there had been 
an injury of the skull, to which we thought the paroxysms 
might be due. In this case the bromide was only partially 
successful. It is included among the cases previously cited. 
The operation is, I think, entirely proper in cases apparently 
the result of injury to the cranium, and several successful 
instances are on record. 

But, before resorting to any specific treatment for epi- 
lepsy, diligent search should be made for the cause, and this 
should be removed, if possible, without the least delay. 
Often an eccentric irritation, such as worms in the intesti- 
nal canal, implication of a nerve in an injury, disorders of 
menstruation, etc., can be discovered, without the removal 
of which a permanent cure is impossible. In several of the 
cases cited, success in the treatment was in a great measure 
due to acting on this principle. 

The hygienic management of the patient is important. 
A large portion of the day should be passed in the open air, 
bodily exercise should be regular, but not excessive — the 
food should be nutritious, but neither exciting nor indiges- 
tible. The importance of avoiding every alimentary sub- 
stance, calculated to cause gastric or intestinal irritation, 
cannot be overestimated. I have frequently seen parox- 



588 CEREBROSPINAL DISEASES. 

ysms directly caused by nuts, dried fruits, pastry, heavy and 
badly-baked bread, excess in the use of alcoholic liquors, 
confectionery, and the like. The bowels must be kept 
regular. Baths should be frequently taken, but should not 
be so cold as to cause severe shock or physical depression. 
Turkish baths, I am inclined to think, are useful in many 
cases, particularly in those occurring in persons of full and 
gross habit of body. 

Overheated and ill-ventilated apartments should be 
avoided. The clothing should be warm in winter and cool 
in summer. The mind should not be overtasked and the 
emotions must not be unduly excited. 

Individual attacks may sometimes be prevented. One 
gentleman under my charge assures me that he can often 
dissipate the premonitory symptoms, and thus stop the de- 
velopment of the paroxysm by a strong exertion of the will. 
Another can arrest them sometimes by changing the posi- 
tion of his body. If standing, he lies down; if lying down, 
he rises suddenly and paces the room violently. Another 
stops them by putting salt in his mouth, and two can fre- 
quently prevent them by tightening straps which I have in- 
structed them to keep constantly around the wrist. In all 
these cases there is an aura, and in the two latter it appears 
to start from the hand. 

A short time since I instituted, at the New York State 
Hospital for Diseases of the Nervous System, a series of 
experiments with the chloride of sodium in the treatment 
of epilepsy, but, although the salt was given in large doses, 
it produced no marked effect. I was led to these investi- 
gations by the facts that the bromide of potassium, the bro- 
mide of sodium, and the chloride of potassium, had been 
employed with success, and I thought there was sufficient 
analogy to warrant the hope that the chloride of sodium 
might prove beneficial. 

As regards other remedies for epilepsy, I have but little 
to say. Belladonna has never in my hands produced the 



EPILEPSY. 589 

least effect, neither has digitalis, nor indigo, nor cotyledon 
umbilicus, nor any of the salts of copper. I might say the 
same thing of the other so-called remedies. Hydrate of 
chloral in three cases mitigated the frequency of the parox- 
ysms, but only for a short time. In several other cases it 
was without effect ; Calabar bean was slightly beneficial in 
one case. 

The treatment during the paroxysm remains to be con- 
sidered. It is simple, and, beyond a few obvious measures, 
consists in letting the patient alone. The head should be 
elevated, the collar and cravat loosened, a piece of soft wood 
put between the teeth so as to prevent injury to the tongue, 
and the patient so placed that he cannot fall or otherwise 
injure himself in his struggles. During the subsequent stu- 
por he should be kept quiet. Bloodletting is never neces- 
sary, although it is recommended as proper in certain cases 
by Jaccoud. 



CHAPTEK III. 

CATALEPSY. 

Although there are no post-mortem appearances charac- 
teristic of catalepsy, the phenomena of the disease observed 
during life point to its seat in the brain and spinal cord. 
Like epilepsy, therefore, it is a symptom representing an 
unknown morbid change in the nervous centres. 

Symptoms. — Catalepsy is an affection marked by the 
occurrence of peculiar paroxysms at regular or irregular 
periods. The seizures usually come on with suddenness, 
and are characterized by more or less complete suspension 
of mental action and of sensibility, and by the supervention 
of muscular rigidity, causing the limbs to retain, for a long 
time, any position in which they may be placed. The phe- 
nomena, therefore, relate to the mind, to sensation, and to 
motion. 

The suspension of mental action is, in general, complete, 
but in some cases there are an imperfect consciousness and an 
ability to appreciate strong sensorial impressions. Thus, in 
a case quoted by Dr. Chambers from Dr. Jebb — which, how- 
ever, was clearly a case of catalepsy complicated with hys- 
teria — the patient, before emerging from the paroxysm, 
sang " three plaintive songs in a tone of voice so elegantly 
expressive, and with such affecting modulation, as evidently 
pointed out how much the most powerful passion of the 
mind was concerned in the production of her disorder, as 
indeed her history confirmed." 1 

1 Art. Catalepsy, in Rcvnolds's System of Medicine, vol. ii., p. 100. 



CATALEPSY. 591 

The aspect of a cataleptic patient is very striking. The 
eyelids are sometimes wide open, at others gently closed ; 
the pupils are dilated, and do not respond to strong light ; 
the respiration is slow, regular, but generally so feeble as to 
be perceived with difficulty ; the pulse is usually almost im- 
perceptible, but is rhythmical and sluggish ; the face is pale, 
the mouth is half open, and the rigidity of the body, and 
the coldness of the extremities, add to the death-like appear- 
ance which impresses all beholders. 

The cutaneous sensibility is ordinarily completely abol- 
ished. Pins may be stuck into the skin and they are not 
felt ; but, owing to the abolition of the power of motion 
and of reflex action, it is possible that in some cases, at 
least, the patients would give evidence of sensation if they 
could. Cases are on record in which tears have been caused 
by excessive emotional disturbance excited by the words or 
actions of persons surrounding the patients, thus showing 
that the senses of sight and hearing were capable of being 
exercised. Such instances are, however, rare, and are prob- 
ably imperfectly-developed paroxysms, or those complicated 
with hysteria or ecstasy. 

The symptoms relating to the muscles are very remark- 
able. Coming on, as the paroxysm usually does, without 
warning of any kind, the patient is at once arrested in any 
act which is being performed, and the whole body assumes 
a condition of extreme rigidity. The power of the will over 
the muscles is lost, and the limbs preserve any position in 
which they may be placed by the by-standers. Thus, if the 
arm be raised from the side, it remains extended, and may 
keep this position for an hour or longer before it sinks slowly 
back to its original situation. No matter how awkward or 
irksome the position may be, it is retained till the exalted 
irritability of the muscles becomes thoroughly exhausted. 

The ability to swallow is not lost, and the electric con- 
tractility of the muscles is not perceptibly affected one way 
or the other. 



592 CEREBROSPINAL DISEASES. 

The paroxysm may last a few minutes or hours, or may 
be prolonged to sey.eral days. 

The temperature of the body, in all the cases that have 
come under my observation, was reduced from two to four 
degrees below the normal standard, and in the extremities 
much more than this. 

The paroxysm generally disappears with as much abrupt- 
ness as marked its accession. A few deep inspirations are 
taken, the eyes are opened, or lose their fixedness, the mus- 
cles relax, and consciousness is restored. In fully-developed 
seizures the patient has no knowledge of what has transpired 
during the attack. 

Seven cases of true catalepsy, uncomplicated either with 
hysteria or ecstasy, have been under my professional care. 
In two of these the seizures were more or less imperfectly 
developed, and strong sensorial excitations were, in a meas- 
ure, perceived and recollected after emergence from the 
attack. But in every instance the character of the impres- 
sion was misinterpreted. A bright light thrown upon the 
eyes with a mirror was spoken of as an " angel's wing which 
brushed across my face," and the scratch of a pin was re- 
membered as " a piece of ice being drawn over the skin." 

In these cases there was the consciousness of mental 
action during the paroxysm, but it was difficult for the 
patients to describe the thoughts which took place. They 
appeared to be somewhat of the nature of dreams. In both 
cases the muscular rigidity was well marked, but was not 
excessive, and appeared to be mainly manifested in the ex- 
tensors. It was not difficult to extend the arm or the leg, 
but flexion required the exertion of a good deal of strength. 

In the other ^.yg cases the paroxysms were completely 
formed. Consciousness was entirely abolished; there was 
no sensibility anywhere, and no reflex actions could be ex- 
cited except those of deglutition.. In one of these cases, 
seizures several times occurred in my consulting-room, and 
I had the opportunity of ascertaining the effect of electricity. 



CATALEPSY. 593 

If the arm was extended, the strongest induced current I 
could apply to the biceps, though causing contraction, failed 
to procure flexion, but relaxation of the extensors was at 
once produced by the application to them of the primary 
current. 

I likewise, in this case, repeatedly examined the fundus 
of the eye with the ophthalmoscope, and invariably found 
the choroids pale, and the retinal vessels straight and atten- 
uated. 

In none of these cases was there any knowledge of what 
passed during the paroxysms, and no consciousness of there 
having been any mental activity. 

Cataleptic persons are usually of dull and sluggish men- 
tal and physical organization. Such has certainly been the 
case in all the instances that have come under my observa- 
tion. The disease does not ordinarily show any decided 
tendency to become worse, either as regards the severity or 
frequency of the paroxysms, provided the exciting causes 
be avoided. On the contrary, there is often a well-marked 
natural tendency to spontaneous cure, or, at least, to a cure 
through the influence of purely hygienic influences, moral 
as well as physical. 

In the majority of cases catalepsy is complicated with 
hysteria or ecstasy, and sometimes with epilepsy. Of this 
latter combination I have seen two cases, and in one of these 
ecstasy was also a feature. This case I have recently 
alluded to in another communication. 1 The patient was a 
young girl, was cataleptic on an average once a week, and 
epileptic twice or three times in the intervals. Five years 
previously she had spent six months in France, but had 
not acquired more than a very slight knowledge of the 
language — scarcely, in fact, sufficient to enable her to ask 
for what she wanted at her meals. Immediately before her 
cataleptic seizures, she went into a state of ecstasy, during 
which she recited poetry in French, and delivered harangues 

1 The Physics and Physiology of Spiritualism. New York, 1871, p. 55. 
38 



594 CEREBROSPINAL DISEASES. 

about virtue and godliness in the same language. She pro- 
nounced at these times exceedingly well, and seemed never 
at a loss for a word. To all surrounding influences she was 
apparently dead ; but she sat bolt upright in her chair, 
staring at vacancy, and her organs of speech in constant 
action. Gradually, she passed into the cataleptic parox- 
ysm, in which she usually remained for from one to three 
hours. Many cases of the combination of catalepsy with 
hysteria and ecstasy have become celebrated in other rela- 
tions than those of true science. 

Causes. — Among the predisposing causes, sex is the most 
efficient. All my cases were in females, and the instances 
of the disease occurring in males are very rare. Heredi- 
tary influence is likewise generally apparent. Of the seven 
uncomplicated cases under my observation, all had relatives 
affected with some well-marked disease of the nervous 
system. In two cases, there were near relatives insane ; in 
two, the mothers were hysterical ; in one, a brother was 
epileptic ; in one, the father was similarly affected ; and, in 
one, a sister was cataleptic. It rarely begins after the age 
of twenty-five. Of exciting causes, emotional disturbance 
stands first. Four of my cases were directly the result 
— one of fright, one of anger, one of grief, and one of the 
shock caused by a boy starting out suddenly from behind a 
door where he had been concealed. In one other case, the 
cause was worms in the intestinal canal ; and, in the other 
two, I could not ascertain with certainty what the cause 
was, though I had strong reasons for suspecting it to be 
masturbation. 

The diagnosis is not a matter of the least difficulty to 
any one who has even an imperfect knowledge of the phe- 
nomena, except, perhaps, as regards its discrimination from 
hysteria, that simulator of almost every nervous disease. 
In those cases complicated with hysteria, the distinction is 
of no importance ; in others, the uniformity of the charac- 
teristics which indicate catalepsy, with a consideration of 



CATALEPSY. 595 

the general history of the case, will serve to make the diag- 
nosis sufficiently precise. It must, however, be borne in 
mind that the two diseases are near of kin, and that the 
discrimination is important more as a matter of abstract 
science than as one of any bearing on the therapeutics. It 
is, however, sometimes a matter of moment to distinguish 
between the cataleptic paroxysm and death. In former 
times, instances were not uncommon in which the mistake 
was made, to be discovered after life had really become 
extinct in the coffin. Such fatal errors would probably be 
impossible now with the stethoscope for examining the 
heart, the thermometer for determining the temperature, 
electricity for acting on the muscles, and, above all, the 
ability to place the limbs in positions which they maintain 
against the laws of gravity. Moreover, our knowledge of 
diseases in general is such as to enable us to determine with 
great certainty -the course they are liable to take, and -the 
manner in which death occurs in each. 

Prognosis. — This is usually favorable, even in severe cases. 
All my patients recovered under the treatment to be pres- 
ently mentioned. 

There is scarcely any thing to say under the head of 
morbid anatomy. It has been stated * that, in the few cases 
in which post-mortem examinations have been made of 
persons dying while cataleptic or subject to seizures, the 
Pacchionian bodies were found enlarged, but I have been 
unable to trace the assertion to its source. 

The pathology of catalepsy is very imperfectly known. 
The symptoms show that the brain and spinal cord are 
involved, and there is some evidence to show that they are 
in a state of ansemia. But there is a condition induced in 
these organs which is the essential feature of the disease, 
and of this we know nothing. There is a possibility that 
the affection may be a masked form of epilepsy, and this 

1 Art. " Catalepsie " in Nouveau Dictionnaire de Medecine et de Chirurgie 
pratiques, t. sixieme, p. 456. Paris, 1867. 



596 CEREBROSPINAL DISEASES. 

view is borne out by the fact that the treatment which is 
most successful in this latter disease is most efficacious in 
catalepsy. 

Treatment. — The bromide of potassium, or one of the 
other bromides previously mentioned under the head of 
epilepsy, is the most efficient agent in the treatment of 
catalepsy. I have never yet failed to cure the disease with 
this remedy, combined with the oxide of zinc, and with the 
simultaneous use of strychnia and other tonics. I have 
never, however, had occasion to give it in larger doses than 
twenty grains, three times a day, or to continue it beyond 
eight months. 

In no disease of the nervous system, not even excepting 
hysteria, is it more necessary that the mind should be 
brought under proper discipline and kept as far as possible 
from the operation of all causes calculated to promote emo- 
tional excitement. At the same time a well-regulated sys- 
tem of hygiene, as regards all the physical requirements of 
the body, is indispensable. 



CHAPTEK IV. 

ECSTASY. 

Though closely allied to catalepsy, ecstasy diners from 
it in several important particulars. One of the main points 
of difference is that the patient recollects the train of 
thought which has been going on during the seizure, and 
this of itself is sufficient to warrant their being separately 
considered. It often happens, however, that the two dis- 
eases alternate or coexist. 

Symptoms. — In ecstasy there is muscular immobility rath- 
er than rigidity ; the eyes are open, the lips parted ; the 
face is turned upward, the hands are often outstretched ; the 
body is erect and raised to its utmost height. A peculiar 
radiant smile illumes the countenance, and the whole aspect 
and attitude is that of intense mental exaltation. 

The mind is so filled with some particular train of 
thought, that excitations of the senses, if of moderate 
intensity, are not perceived. We meet with this fact often 
in normal conditions, when the mind is deeply engaged in 
reflection, or when it is engrossed with some powerful emo- 
tion. 

Most of the religious impostors who have at various 
times made their appearance, and many very sincere and 
devout persons, have been ecstatics. 

In its combinations with catalepsy, chorea, and hysteria, 
ecstasy has frequently played an important part in the his- 
tory of the civilized world — at one time, leading to a be- 
lief in witchcraft ; at another, to demoniac and angelic pos- 



598 CEREBROSPINAL DISEASES. 

session ; at another to mesmerism and clairvoyance ; and, 
in onr day, to spiritualism. The consideration of these fol- 
lies, though interesting, scarcely comes within the scope of 
the present treatise. 

Causes. — Ecstasy, though not entirely confined to the 
female sex, is very much more common in women than in 
men. It appears to be produced in those who are of deli- 
cate and sensitive nervous organizations by intense mental 
concentration on some one particular subject — generally, 
one connected with religion, or some other abstract train of 
thought. It was formerly quite common among the in- 
mates of convents, and is now not unfrequently met with 
at camp-meetings and spiritualistic gatherings. 

There are no points about the diagnosis requiring special 
consideration, and the prognosis is always favorable, if the 
subject can be submitted to proper moral and physical 
treatment. As the disease is never fatal jper se, we know 
nothing of its morbid anatomy. The pathology, as indicated 
by the symptoms, points to the implication of both the 
brain and spinal cord, but there is no satisfactory theory 
of the disorder other than that which refers it to cerebral 
and spinal preoccupation — a kind of setting of the current 
in one direction, whereby all other occupation is for the 
time prevented. 

Treatment. — The means of treatment, though not differ- 
ing essentially from those proper for catalepsy, require, 
nevertheless, special mention of some particulars. The in- 
fluence of moral force in preventing and curing ecstasy is 
well marked, and many instances are on record in which 
epidemics of it have been arrested by arguments addressed 
to the fears of the subjects. I have several times aborted 
and prevented ecstatic manifestations by making prepara- 
tions to cauterize the region of the spine with a red-hot 
iron. 

A great deal can be done by giving as little notoriety to 
ecstatics as possible. They glory in the idea that they are 



ECSTASY. 599 

of sufficient importance to excite attention and discussion, 
and they are accordingly stimulated to continue their per- 
formances so long as they are noticed, and an air of mystery 
is attached to them. 

Removal from all associations calculated to continue the 
exciting and morbid train of thought which has developed 
the disease under notice should, of course, be a point in the 
treatment. 

Electricity, and the other measures of treatment recom- 
mended for catalepsy, will prove serviceable in ecstasy. By 
galvanization of the sympathetic nerve, I, on one occasion, 
immediately cut short a paroxysm of ecstasy, and, by con- 
tinuing the practice every alternate day for about six 
weeks, eifectually cured the patient, who for several years 
had been subject to seizures every two or three days. 



CHAPTEK V. 

CHOREA. 

Although it is quite certain that several distinct affec- 
tions are included under the term " chorea," these are analo- 
gous to each other, and, as we know little about the essen- 
tial anatomical features of these disorders, and as they are 
allied by their symptoms, it will be advisable, for the pres- 
ent, to consider them together. 

Symptoms. — Even in simple typical and uncomplicated 
cases of chorea, the symptoms exhibit great variety. They 
are connected mainly with the mind, with motility, and 
with sensibility, though, at the same time, the functions of 
organic life are generally more or less deranged. 

Among the earliest symptoms of chorea are those refer- 
able to disordered brain -action. The character and disposi- 
tion of the patient undergo a marked change, and there is, 
besides, from the first, a very decided impairment of mental 
vigor. The emotions are easily excited, and the temper 
becomes fretful and irritable. Hallucinations are not un- 
common, and these are generally connected either with 
the sight or hearing. Sometimes both these senses are in- 
volved. 

The sleep is generally disturbed by disagreeable dreams, 
sometimes reaching to the intensity of nightmare, and these 
are so vivid that the patient often considers them realities. 

In a few cases, there is decided mania, but this is not of 
a very aggravated form, and is of temporary duration. 
Three such instances have recently been under my care, all 



CHOREA. 601 

occurring in young girls of about the age of puberty, and 
exhibiting in all other respects the typical characteristics of 
chorea. 

In two cases under my observation, the first notable 
event in the course of the disease was an epileptic parox- 
ysm, which, however, was not repeated in either case. 

The most prominent symptoms of the disease are, in 
the great majority of cases, exhibited in the irregular and 
disorderly muscular contractions which make their appear- 
ance at a very early period, and which have given it a name 
in nearly every language of the civilized world. Thus, we 
have the terms chorea (^ope/a, a dance), St. Yitus's dance, 
St. Guy's dance, etc. 

In the beginning the foot of one side drags a little, and 
soon afterward the corresponding upper extremity becomes 
affected with the choreic movements. These are manifested 
in the fingers, in the flexion, extension, and rotation of the 
wrist, and in the movements of the elbow and shoulder. 
"No matter where the hand be placed, it cannot be kept 
steady, but it and the whole extremity are in a constant 
state of agitation. Before long the muscles of the neck and 
face participate, the head is jerked from side to side, and a 
continual series of grimaces is the result of the actions in 
the facial muscles. 

In some cases the involuntary movements are confined 
to one lateral half of the body, constituting the form known 
as hemichorea. This is the case in about one-fourth of the 
cases. Thus, of two hundred and thirty-five cases cited by 
See, 1 the phenomena in sixty-four were limited to one side. 
This limitation has not, as was formerly supposed, any rela- 
tion with hemiplegia, but is solely the result of the suspen- 
sion of the progress of the disease. 

At first the movements are moderate, but they go on, be- 

1 De la choree et des affections nerveuses en general, avec leurs rapports 
avec les diatheses, et principalement avec le rheumatisme. Mem. de l'Academie 
de Medecine, 1850, t. xiv., p. 343, et seq. 



602 CEREBROSPINAL DISEASES. 

coming more and more severe, until, in extreme cases, the 
condition of the patient becomes exceedingly pitiable. The 
arms, the legs, the face, and head, are in almost constant 
action. Every attempt to perform a voluntary movement 
excites still more the disorderly actions, and thus the patient 
is unable to feed or dress himself, and sometimes even walk- 
ing becomes impossible. 

In one type of cases the convulsive movements come on 
paroxysmally, and are often of the most astonishing charac- 
ter. The patient is, perhaps, lying quietly on the bed, when 
suddenly the head is thrown backward, the limbs set in in- 
voluntary motion, and the muscles of the trunk contract 
so violently as to throw the sufferer forcibly to the floor. 
Again, a series of gyratory motions ensues, and the patient 
turns round on one foot until complete exhaustion follows ; 
or there may be leaps and contortions of various kinds. 
Sometimes the movements are rhythmical. A lady, who a 
short time since was under my charge, was suddenly seized 
with an irresistible impulse to bend the left elbow. The 
arm continued in motion for half an hour, and then the 
right arm began a like movement. In a few minutes the 
head began to nod, then the left knee was alternately flexed 
and extended, and finally the right knee became similarly 
affected. For over an hour these movements continued, 
and then a regular alternation ensued — first the left arm, 
then the right, then the head, next the left leg, and finally 
the right leg. These actions were perfectly timed, and 
were all performed in exactly ten seconds, as I ascertained 
by determinations made on several occasions. As she sat 
in a chair, or lay on a bed, she was a curious sight. Though 
she was good-tempered with it all, her emotional system 
was in a state of great exaltation. She recovered in a few 
weeks. 

In another case a lady from New Jersey was affected in 
a still more extraordinary manner. While sitting sewing 
one day, after having been greatly fatigued the previous 



CHOREA. g03 

night, her leg began to tremble violently. In a few minutes 
the arm of the same side became involved, and very soon 
the other limbs and the head were affected. She was now 
in a state of general tremor, and, on attempting to rise, fell 
to the floor. She was then seized with another kind of 
movement. Her legs were drawn . np forcibly, and then 
suddenly extended, and this with inconceivable rapidity. 
She was placed on a bed, but was unable to stay there un- 
less held by several persons, so strong were the contractions 
which took place. On one occasion she was thrown over 
iive feet, her body coming to the floor with great violence. 

The following day afresh series of phenomena ensued. 
She began to turn somersets, and continued these actions 
for several hours without appearing to be greatly exhausted. 
Then she jumped suddenly to her feet, and rushed round in 
a circle with such swiftness that she could not direct her 
steps, and she several times knocked her body with great 
force against the walls and furniture. Then she danced for 
several hours, and toward evening became tolerably quiet, 
though there was still involuntary twitching of nearly all the 
muscles. In all the various movements she went through, 
every attempt to hold her only made her worse, and she 
begged that she might be let alone, as the effort to control 
her by physical force made her head swim, and gave her a 
severe headache. At night the paroxysms ceased, but they 
were renewed as soon as she awoke in the morning, and 
continued with but little intermission, and in every possible 
form, till she went to sleep. 

On the third day I visited her, and found her in the 
midst of a series of movements such as I have described. 
Her pulse was irregular, her respiration hurried, and her 
countenance evinced great anxiety. There was no evidence 
of any hysterical complication. 

I at once proceeded to administer chloroform by inhala- 
tion, and in a few moments she was completely under its 
influence. The paroxysms ceased soon after the inhalation 



604 CEREBROSPINAL DISEASES. 

was begun. I kept her in a state of anaesthesia for half an 
hour. When she recovered consciousness she was perfectly 
composed, and remained so all the rest of that day. I left 
directions that the inhalation was to be repeated if there 
should be any return of the choreic paroxysms, but there 
were none. She slept well all night, and the following 
morning was quiet till about eleven o'clock, when a slight 
tremor began, which was at once quieted by the chloroform. 
I saw her again that day, and began a treatment consisting 
mainly of strychnia in gradually-increasing doses, and re- 
newed my directions in regard to the chloroform. After 
this she had a few attempts at paroxysms, but they were 
always stopped by the inhalation of the chloroform, and in 
a few weeks she was well. 

Chorea of rhythmical or uniform character has often pre- 
vailed epidemically. The most authentic recorded visita- 
tion of the kind was one which occurred at Aix-la-Chapelle 
in 1374. This was in the form of a dancing mania, and is 
fully described by Hecker x under the name of St. John's 
Dance. The men and women subject to it met in the 
streets and churches, where " they formed circles hand-in- 
hand, and, appearing to have lost all control over their 
senses, continued dancing, regardless of the by-standers, for 
hours together in wild delirium, until at length they fell to 
the ground in a state of exhaustion. They then complained 
of extreme oppression, and groaned as if in the agonies of 
death, until they were swathed in cloths bound tightly 
around their waists, upon which they again recovered, and 
remained free from complaint until the next attack. This 
practice of swathing was resorted to on account of the 
tympany which followed these spasmodic ravings, but the 
by-standers frequently relieved patients in a less artificial 
manner, by thumping and trampling upon the parts affected. 
While dancing they neither saw nor heard, being insensible 
to external impressions through the senses, but were haunt- 
1 Epidemics of the Middle Ages. Sydenham Society Translation, 1844, p. 87. 



CHOREA. 605 

ed by visions — their fancies conjuring up spirits, whose 
names they shrieked out ; and some of them afterward as- 
serted that they felt as if they had been immersed in a 
stream of blood, which obliged them to leap so high. Oth- 
ers, during the paroxysm, saw the heavens open and the 
Saviour enthroned with the Yirgin Mary, according as the 
religious notions of the age were strangely and variously re- 
flected in their imaginations." 

In the most fully-developed and best-marked instances 
of the disease, it was often ushered in by an attack of epi- 
leptic convulsions. 

The affection spread like wild-fire — being fed by that 
principle of imitation which appears to be so powerful an 
influence in causing the propagation of this and analogous 
disorders of the nervous system. Those affected were gen- 
erally regarded as being possessed by evil demons, and con- 
sequently only to be cured by the exorcisms of the clergy. 

In 1418 it broke out in Strasbourg, and there received 
the name of St. Titus's dance, from the fact that the most 
efficacious means of cure was thought to consist in the inter- 
cession of this saint. 

Similar attacks of dancing mania had occurred before 
that of St. John, but the details are more or less obscure, 
and several have occurred since. Among these latter must 
be placed the tarentism which overran Italy, and various 
more restricted epidemics of like disorders. In our own 
country we have had the Jumpers, and we still have the 
Shakers. In addition to these are many of the manifesta- 
tions of witchcraft, which were choreic, and of which this 
country has had its full share, and of spiritualism, which it 
enjoys the doubtful honor of having initiated. 1 

In chorea, even of the ordinary simple kind, the speech 
is imperfect, owing to the incoordination of the muscles 
directly concerned in articulation, and those which effect 

1 See the author's " Physics and Physiology of Spiritualism " for more com- 
plete details on this and analogous subjects, and for accounts of other examples. 



606 CEREBRO-SPINAL DISEASES. 

respiration. There are therefore stuttering and stammer- 
ing, and at times a peculiar difficulty of speaking, owing to 
the attempt being made when the chest is empty ; that is, 
when expiration has first been accomplish ed> The tongue 
and lips rarely escape being involved to a considerable ex- 
tent. 

The muscles of mastication and deglutition are gener- 
ally affected, and hence the food is imperfectly chewed, and 
often causes choking from difficulty of swallowing it. 

In some cases chorea is accompanied with paralysis — 
the chorea paralytica of authors. This loss of the power 
of voluntary motion is usually hemiplegic ; and involves the 
same muscles, which are the seat of the irregular move- 
ments. Occasionally there are contractions of the limbs, 
but not to any great degree. 

Chorea is sometimes of very limited extent. It may be 
only shown in the hand or foot, but more frequently, when 
restricted in its topography, it is manifested in the head or 
face. There may be only a little twitching of the muscles 
at the angles of the mouth, or of those which raise the upper 
lip, or of the orbicularis palpebrarum, by which the eyelids 
are closed, or of the levator palpebrse superioris, or of the 
corrugator supercilii, or occipito- frontalis. Sometimes the 
head is rotated suddenly, or twitched to one side, or there is 
a shrugging of the shoulders. 

In several cases that have been under my care, the ab- 
normal manifestations were entirely confined to the organs 
of voice or speech. In one instance — that of a young girl 
from Illinois — while there was a general hyperesthesia of 
the whole nervous system, there were no choreic movements 
except of the respiratory and laryngeal muscles. The res- 
piration was therefore exceedingly irregular, and at times 
inarticulate sounds were made, which were involuntary. 
Articulate speech was lost from inability to coordinate the 
muscles, but there was no paralysis, for the tongue could be 
moved freely in all directions, and the lips were as mobile 



CHOREA. (307 

as ever, except when the patient made an effort to speak- 
After a few weeks the sound from the larynx was made 
regularly at each expiration. There were no sounds during 
sleep. 

In this case there was a strong hysterical element pres- 
ent. The affection resisted all treatment, and finally I sent 
the patient home, scarcely improved except in her general 
health. One morning she awoke, began to speak, and there 
was no resumption of the laryngeal sounds. She has con- 
tinued well ever since, now over two years. 

Again, there may be an irregular action of the muscles 
of speech, and in consequence words are uttered against the 
will of the patient, and often without any previous knowl- 
edge of what is going to be said. Several such cases have 
been under my observation, and I have alluded to two of 
them in a recent lecture 1 on chorea. Since then another 
remarkable case of the kind has come under my care. In 
this instance there is scarcely a minute during the day that 
the speech is not going on, and this without the least power 
on the part of the patient to arrest or direct it. If he is 
asked a question, he can only use a few apposite words, the 
others being altogether without relation to the subject about 
which he wishes to speak. 

The convulsive movements in chorea almost invariably 
stop during sleep. They are also sometimes temporarily 
arrested by intense mental occupation, but are always ren- 
dered worse by emotional disturbance or physical fatigue. 
On the contrary, they are diminished by mental and emo- 
tional quietude. 

Strange as it may appear, the sensation of being tired is 
scarcely ever experienced by choreic patients. Generally, 
however, there are wandering pains in the limbs, headache, 
and pain in the back. The cutaneous sensibility is usually 
increased, but in some cases it is greatly lessened, and may 
be abolished altogether in some parts of the body. 

1 Journal of Psychological Medicine, January, 1871, p. 51. 



608 CEREBROSPINAL DISEASES. 

The functions of the several viscera are ordinarily more 
or less deranged. There are paroxysms of palpitation of 
the heart, and the action of this organ is to some extent 
irregular during the whole course of the disease. Endocar- 
dial murmurs are often present, either systolic or diastolic, 
but are the result of the anaemia which is so prominent a 
feature of chorea. Respiration is imperfect ; the stomach 
does not digest well ; and there are nausea and vomiting. 
The bowels are constipated ; the urine is loaded with phos- 
phates, and is of diminished quantity; and the menstrual 
function in girls is imperfectly performed, either as regards 
quantity or quality. The skin is dry and harsh, the hair 
loses its gloss, the complexion is pale, the lips bloodless, the 
pupils dilated, and the sclerotic coat of the eye of more 
than normal whiteness. 

The tendency of chorea is to increase to a certain point, 
and then to gradually diminish. In favorable cases occur- 
ring in children, it runs its course in about three months. 
This period can be materially shortened by appropriate 
treatment. Sometimes, it ceases very suddenly, and, in 
others, passes into a chronic condition, which may last for 
years or during the life of the patient. Occasionally, it 
terminates in death, either directly or in consequence of the 
supervention of some intercurrent affection. Three fatal 
cases have come under my observation. One of these I 
saw several times in consultation with my friend Dr. T. G. 
Thomas. The patient was a young lady about twenty 
years of age, and her paroxysms were of the most violent 
character, sometimes being so strong as to cause her to 
throw herself off the bed, or to dash about the room with 
great force. No treatment appeared to exercise any re- 
straining effect, and, after about two years, she died of an 
abdominal affection. There was no post-mortem examina- 
tion. In the other two cases, death ensued from exhaus- 
tion. 

Relapses are common in chorea, especially in children, 



CHOREA. 609 

and sometimes as many as half a dozen attacks occur. 
Subsequent seizures are usually less severe than the first. 

Chorea is often complicated with hysteria — a combina- 
tion which will be described hereafter. It may also exist in 
conjunction with rheumatism and malarial fevers, and the 
exanthemata. 

Causes. — Chief among the predisposing causes of chorea 
is age. It is more frequent during the period extending 
from six to fifteen years than during all the rest of life. 
See, of five hundred and thirty-one cases, found four hun- 
dred and fifty-three of ages ranging from six to fifteen years. 

Of eighty-two cases, occurring in my own experience, 
sixty-seven were of ages between six and fifteen years. 
Under the age of six, the disease is less frequent as we go 
toward birth. Cases have been met with in infants at the 
breast of six months old. The youngest case I have had 
was a girl of eighteen months. 

After fifteen, the disease, unless it occurs as an epidemic, 
is not very common. Cases are, however, met with in 
adults, and even in very old persons. I have seen four 
cases in individuals over thirty and three in persons be- 
tween the ages of twenty and thirty. Of course, I refer to 
the origination of the disease at these ages : instances of 
its beginning in childhood, becoming chronic, and lasting 
through life, are not so rare. In those cases reported by 
authors of the affection originating very late in life, we 
have every reason to conclude that they were instances 
of organic lesions of the brain or spinal cord — probably, 
sclerosis — giving rise to rhythmical movements or paralytic 
tremor. 

The female sex is much more liable to chorea than the 
male. Of See's five hundred and thirty-one cases, three 
hundred and ninety-three were girls and one hundred and 
thirty-eight boys. 

Of my eighty-two cases, seventy were females and twelve 
males. Rheumatism has been supposed to be a predispos- 
39 



£10 CEREBRO-SPINAL DISEASES. 

ing cause of chorea. Of one hundred and twenty-eight 
cases, See found sixty-one in association with rheumatism, 
but, when we come to inquire further, we find that only 
thirty-two of these were articular rheumatism, while the 
rest were cases in which there were wandering pains which 
may have been, and probably were, without the least affinity 
with true rheumatism. 

While it is certainly the case that chorea sometimes fol- 
lows or exists coincidentally with rheumatism, I doubt if its 
influence is any more than that of a depressing agent to the 
organism. Of the eighty-two cases observed by myself, 
only sixteen were connected with rheumatism, while eigh- 
teen were just as intimately related to other diseases. 

The affection appears to be more common in winter than 
in summer. Of my cases, fifty-four occurred in the six 
months from October to March, and twenty-eight in the 
other six months of the year. 

Among the exciting causes, those connected with the 
emotions occupy the first place. Twenty-seven of my cases 
were directly the result of fright, apprehension, anxiety, 
mental excitement, or some other cause of the kind. In eight 
it was induced by intense study at school, and in four from 
imitating others similarly affected. This latter factor is not 
of so general application as in former times, when social life 
was different. To it is doubtless to be ascribed the spread 
of choreiform movements through certain localities, and 
especially convents, such as occurred in the thirteenth, four- 
teenth, and fifteenth centuries, to some of which reference 
has already been made. 

Among other causes, bad hygienic influences and ex- 
hausting diseases generally are to be mentioned. 

Pregnancy is also asserted to be a cause, and cases are 
on record in which the foetus has been born choreic of a 
choreic mother. 

Diagnosis. — There is not much danger at the present day 
that chorea will be confounded with many of the diseases 



'CHOREA. 611 

from which, not long ago, it was not clearly disassociated. 
Thus from paralysis agitans, epilepsy, locomotor ataxia, 
cerebral and cerebro-spinal sclerosis, the fuller acquaintance 
which we have in recent years acquired of these maladies 
prevents the necessity of dwelling on their characteristics 
as distinguished from those of chorea. The course of the 
latter disease and the symptoms, other than those connected 
with motility, are in the others so different that no one who 
has studied their phenomena could fail in making a correct 
diagnosis. 

With hysteria, some of the forms of chorea may be con- 
founded, and the two affections are not infrequently blended 
in the same person. It must be confessed, too, that there 
are cases in which the diagnosis cannot be clearly made out, 
So far as the patient is concerned, the difficulty of forming 
a correct opinion in such cases is not a matter of much mo- 
ment. 

The great majority of cases of chorea, such as are met 
with in children, are readily distinguished from hysteria. 
The facts of the disease occurring before puberty in so large 
a proportion of instances, that the emotional system is 
rarely disturbed as in hysteria, that the affection is not so 
paroxysmal, and that the accessions of hysteria are more 
sudden, will be sufficient to render the diagnosis accurate. 

Prognosis. — This is usually favorable in those cases which 
occur before puberty. The chorea of adults is, however, in 
most instances, a very unmanageable affection, and gener- 
ally either terminates in death or becomes permanent. 
Cases in which death has ensued have been reported by 
various authors — among them, Dr. John W. Ogle, 1 Dr. J. 
Hughlings Jackson, 3 and Dr. Gr. See. 3 As already stated, 

1 Remarks on Chorea Sancti Viti, including the History, Course, and Termi- 
nation of Sixteen Fatal Cases, etc. British and Foreign Medico-Chirurgical 
Review, January, 1868, p. 208. 

2 The Physiology and Pathology of Hemi-Chorea. Edinburgh Medical 
Journal, October, 1868. 3 Op. cit. 



612 CEREBRO-SPINAL DISEASES. 

three fatal cases have occurred in my own experience. The 
tendency, however, in the chorea of young persons is decid- 
edly toward recovery, even under unfavorable circumstances 
as regards hygiene or medical treatment. 

Morbid Anatomy and Pathology. — In many cases of persons 
dying, either from chorea or from intercurrent affection, no 
changes have been found which could, with probability, be 
regarded as constituting the disease. In other cases, mor- 
bid alterations from the healthy state have been found. 
The idea has, therefore, prevailed that there are two kinds 
of chorea — one which is entirely functional, belonging to 
the so-called neuroses, the other the result of organic disease 
of the brain or spinal cord, or both. In Ogle's sixteen fatal 
cases, congestion of the brain and its membranes was found 
in some, while in others the difficulty existed in the spinal 
cord. 

In an analysis of one hundred cases of chorea, Dr. 
Hughes * cites fourteen fatal cases. In all but four of these 
there was intra-cranial congestion with other structural 
changes, such as softening, opacities and adhesions. The 
spinal cord was not examined in six cases. Of the remain- 
ing eight, it was healthy in three, and congested, softened, 
or with adhesions or opacities of the membranes in the re- 
maining five. 

In seven fatal cases, collected by Romberg, 2 there were 
softening and degeneration of different parts of the brain 
and of the spinal cord. 

Other similar cases have been reported, and in the ma- 
jority there were fibrinous concretions on some portion of 
the heart's valves or lining membrane. 

In 1850 and 1863, Dr. Senhouse Kirkes 3 published the 
details of a number of cases which went to show the asso- 

1 Digest of One Hundred Cases of Chorea. Guy's Hospital Reports, vol. iv., 
1846, p. 360. 

2 Lehrbuch der Nervenkrankheiten, B. ii. 

3 London Medical Gazette, 1850, and Medical Times and Gazette, 1863. 



CHOREA. 613 

ciation between chorea and rheumatism, and he made the 
prediction that " future experience will still more positively 
demonstrate that an affection of the left valves of the heart, 
with the presence of granular degeneration upon them, is 
an almost invariable attendant upon chorea, under whatever 
circumstances the chorea may be developed." The relation 
is also insisted upon by See and other authors, and such 
cases as those of Ogle are cited in its support. But the 
doctrine is only applicable, with any probability, to the fatal 
cases, and, in those of Ogle, rheumatism was not always an 
antecedent. In regard to this point, I am entirely in accord 
with the views expressed by Dr. Ogle in the following ex- 
tract, which I make from his valuable paper : 

" Again it might be asked, if there was merely a me- 
chanical cause (which, of course, would be constant in 
operation), such as embolism, why should the movements 
be so decidedly and universally interrupted during quiet 
sleep ? Or, why should certain peculiarities as to age or sex 
be considered as predisposing influences ? Recognizing the 
frequent existence of these fibrinous deposits, or granula- 
tions on the heart's valves in chorea, I should be much 
inclined to look upon these post-mortem appearances rather 
as results of some antecedent condition of the blood, common 
also to the choreic condition. It is very freely recog- 
nized that this affection is frequently in some way or other 
connected with that condition of blood which obtains in 
what we call ansemia, or that existing in rheumatic con- 
stitutions. In both of these states we know that the 
fibrine of the blood is much in excess (as also it is in preg- 
nancy and other conditions looked upon as obnoxious to 
chorea), and in these states we know that the fibrine (with 
which the blood is surcharged) is very prone to be readily 
precipitated, either owing to its superabundance or from 
other obscure and acquired properties (possibly also from 
some interference with the relation of the fibrine and the 
other constituents of the blood), upon the heart's walls or 



614: CEREBROSPINAL DISEASES. 

valves. May not this hyperinosis be the explanation of the 
coincidence allnded to ? In most cases, the deposit is 
probably very slight, and, in many cases, so slight as to 
require search for it. May it not infrequently be that it is 
often only found in quite the dying state ? Speculation 
might suggest that the fibrinous deposits arise from some 
interference with the degree of solubility of the fibrine, 
induced by the presence of some ununited elements within 
the blood (some result of tissue-metamorphosis) produced 
by the excessive muscular action and other functional dis- 
turbance which exists in the choreic state, thus being not 
in any way related to this state as a cause, but as a conse- 
quence." 

In the paper to which reference has already been made, 
Dr. Hughlings Jackson associates hemi-chorea with the 
plugging by emboli of the vessels of the corpus striatum of 
one side, and, in a recent valuable paper, Dr. Charlton Bas- 
tian * says : 

" I need only hint at the important bearing which the 
possibility of the occurrence of minute embolisms of this 
kind may have in the elucidation of previously-obscure forms 
of so-called functional disease of the nervous system, as I 
hope shortly to publish the details of a fatal case of chorea, 
in which such embolisms led to ruptures and obliterations 
of small vessels throughout the corpora striata and in the 
course of the middle cerebral arteries generally — this be- 
ing a case of bilateral chorea in which delirium was also 
present." 

As the result of our present knowledge of the morbid 
anatomy of chorea, while it cannot be said that we are able 
to define its seat with accuracy, we have strong evidence to 
support the view that it is not a neurosis or functional affec- 
tion — if, indeed, there are any such — and that it is the re- 
sult of changes taking place in the cerebro-spinal system. 

1 On the Plugging of Minute Vessels in the Gray Matter of the Brain, etc. 
British Medical Journal, January 30, 1869, p. 96. 



CHOREA. 615 

As previously stated, I am inclined to think that there are 
at least two distinct diseases — one due to spinal and the 
other to cerebral lesion — the latter probably consisting of 
several forms — but that it is advisable to consider them as 
one disease of various types, until further investigation en- 
ables us to speak with certainty on the subject, and to clas- 
sify them according to the morbid anatomical condition of 
each. 

Treatment. — Diseases which are almost certain to termi- 
nate fatally, and those which ordinarily recover without 
medical treatment, are very sure to have a great many 
medicines used in their therapeutics. Chorea belonging, as 
it does, to this latter category, has a medical armamentarium 
almost equalling that of hydrophobia. I shall, of course, 
not even pretend to mention all these measures, but will 
merely cite those which the weight of evidence, and espe- 
cially that derived from my own experience, indicates as the 
most effectual. Of the benefit to be derived from proper 
medical treatment in shortening the duration of the disease, 
and preventing chronicity, I have no doubt. 

In this country zinc is probably more used in chorea 
than any other single remedy. I have employed it in many 
cases, and sometimes with good results. My preference is 
for the sulphate, which I give in gradually-increasing doses, 
from two or three grains up to twenty or thirty three times 
a day, dissolved in a sufficient quantity of water, to prevent 
gastric irritation. When the choreic symptoms begin to 
disappear, the doses should be diminished in the same grad- 
ual manner in which they were increased. 

Iron is also frequently administered as a sole remedy, 
and still more generally as an adjuvant. Indeed, no matter 
what special treatment may be adopted, iron is generally 
indicated to improve the quality of the blood. I rarely use 
it unless for this latter purpose. 

Arsenic enjoys a high reputation in the treatment of 
chorea, and by some is regarded as almost a specific. Al- 



QIQ CEREBROSPINAL DISEASES. 

though. I have several times given it with great advantage, 
I have repeatedly had it fail in my hands. I have admin- 
istered it twice hypodermically for choreic movements in- 
volving the muscles of the neck, as recommended and suc- 
cessfully used by Dr. Kadcliffe. In one of these it failed, 
but in the other it was thoroughly effectual. Five minims 
of Fowler's solution, diluted with an equal quantity of 
water, were injected into the cellular tissue immediately 
over the belly of the left sterno-cleido-mastoid muscle, the 
muscle which was affected. The following day six minims 
were injected, and so on till the quantity reached ten min- 
ims. By this time the jactitations had nearly ceased, and 
a few more injections of ten minims each were sufficient to 
render the cure complete. In this case zinc, electricity in 
the forms of the primary galvanic, and induced currents, 
iron, morphia, and several other measures, had failed. 

Tartarized antimony, copper, sulphate of aniline, Cala- 
bar bean, and various other substances, have been employed 
with more or less success, according to reports, but I have 
no personal experience of their value. 

I have used both the primary galvanic and induced cur- 
rents in sixty cases. In my opinion they are inefficacious 
except in that form in which there is distinct paralysis. 

Without stopping to detail other means, I will describe 
the modes of treatment which my experience has convinced 
me are most efficacious. As one of the remedies, I usually 
administer the bromide of potassium or sodium in moderate 
doses, so as to render the sleep sounder. I do not regard 
this as an essential part of the treatment, and, if the patient 
is exceedingly ansemic, I do not urge it. 

My main reliance is on strychnia, which I think should 
be given in gradually-increasing doses, somewhat after the 
manner recommended by Trousseau. Two grains of the 
sulphate of strychnia are dissolved in an ounce of water, 
and for a child of from ten to fifteen years of age five min- 
ims should be given three times a day. This quantity rep- 



CHOREA. 617 

resents the one forty-eighth of a grain of the salt. The 
following day six minims are administered at each dose, the 
next seven, the next eight, and so on till the physiological 
effects of the medicine, as evidenced by stiffness of the legs 
and neck, are obtained. Sometimes these are not perceived 
till twenty or twenty-five minims are taken at a dose. In 
other cases they follow on doses of ten minims. When they 
take place, the doses should be at once reduced to the origi- 
nal five minims, and the increase carried on as before. This 
plan of treatment certainly shortens the duration of the dis- 
ease very materially, and causes great improvement in the 
general health of the patient. Sometimes the effect is so 
well marked, and is so immediate, that it is not necessary to 
increase the doses to the extent of causing muscular cramps, 
but generally the full therapeutical effect of the drug is not 
obtained till the calf of the leg, or the nucha, has slight tonic 
spasm. I have never seen the slightest ill consequence fol- 
low this mode of treatment, and the doses are increased so 
gradually that with careful watching danger need never be 
apprehended. I have carried it out in thirty-two cases 
occurring in children under the age of fifteen, and in three 
cases in persons of adult years, without a single failure. 

In one of the latter the affection was limited to the 
speech, there being an inability to utter words in accord- 
ance with the ideas. In this case the dose was increased to 
thirty-five minims before any rigidity of the legs was per- 
ceived, and then the command over the language began to 
appear, and by continuing the doses at thirty-five minims 
the patient was entirely cured within a month. In this case 
the initial dose was ten minims. 

Quite recently I have made use of the ether-spray to the 
spine as employed by Lubilski, Zimberlin, and others, and 
my success has been unequivocal. The whole spine is ex- 
posed, and the ether is thrown upon it from the occiput to 
the sacrum for about ten minutes every day, or every alter- 
nate day, according to the severity of the attack. Ten 



618 CEREBROSPINAL DISEASES. 

applications are the maximum number I have found it 
necessary to make, and thus a cure has always been ob- 
tained within two weeks. I have employed this means in 
thirteen cases in my private practice, and in three in the 
~New York State Hospital for Diseases of the Nervous Sys- 
tem. Strychnia has been given at the same time, but un- 
doubtedly the beneficial results are mainly to be attributed 
to the ether. 

In the paroxysmal forms of chorea, ether or chloroform 
by inhalation is often necessary to cut short or prevent an 
immediate seizure, but in other respects the treatment men- 
tioned is entirely applicable. 

In all cases hygienic measures are of the utmost impor- 
tance. Exercise in the open air is indispensable ; the food 
should be of the most nutritious character ; the bedroom 
should be well ventilated ; bathing should be frequent ; the 
bowels should be kept well regulated, and the child, if at 
school, should be at once removed, and all study for the 
time be interdicted. Ridicule or threats, so often indulged 
in toward choreic children, generally do harm, but at the 
same time they should be encouraged to use all reasonable 
effort to prevent a bad habit being formed. In the epi- 
demic variety of the disorder, threats, and even strong re- 
pressive measures, are, on the contrary, decidedly beneficial 
in curing and arresting the further progress of the disease. 



CHAPTEK VI. 

HYSTERIA. 

A laege volume might be written on hysteria — and 
many such have been published — and there would still be 
points in its clinical history unconsidered. It is difficult, 
therefore, in a general treatise like the present, to give a 
full view of a disease which plays so important a part in 
nervous pathology, and which is so varied in its manifesta- 
tions. The most that I can hope to do is to lay down cer- 
tain broad principles and features, and leave the recognition 
of details to the intelligence and discrimination of those 
who read this work. 

Symptoms. — The phenomena of hysteria may be mani- 
fested as regards the mind, sensibility, motility, and visceral 
action, separately or in any possible combination. Thus it 
is not uncommon to meet with cases in which the only evi- 
dence of the disease is seen in abnormal mental action ; 
others are characterized solely by derangements of sensibil- 
ity, such as hyperesthesia or anaesthesia ; others by aberra- 
tion of the faculty of motion, such as paralysis, spasms, con- 
tractions. Again, all of these categories may be witnessed 
in the same person, giving rise, among other phenomena, to 
coma and convulsions ; and again, some one or more of the 
viscera may be deranged in their functions, and thus the 
appearance of organic disease be simulated. 

As there is such a marked want of uniformity in the 
character of hysteria as it affects different persons, I will 



620 CEREBRO-SPINAL DISEASES. 

not endeavor to present a typical case of the disorder, but 
will consider separately the principal phenomena which 
may have an hysterical origin. But, in setting out to 
make the attempt, I am reminded of Dante's despair at the 
thought of his inability to describe the horrors of the ninth 
gulf: 

" Chi poria mai pur con parole sciolte 

Dicer del sangue, e delle piaghe appieno, 

Ch'io ora vidi, per narrar pici volte ? 

Ogni lingua per certo verria meno, 

Per la nostra sermone, e per la mente, 

C'hanno a tanto comprender poco seno." 

The Hysterical Diathesis. — Though it is very common 
to hear the hysterical diathesis or temperament mentioned 
by medical authors, I have never been able to recognize its 
existence by any external traits. The fact that it has been 
so very differently described by writers, from Hippocrates 
and Galen, to our own day, is good evidence that it is not 
readily detected. 

Thus, Hippocrates and Galen recognized the existence 
of the hysterical temperament, but each gave it different 
characteristics. Louyer-Yillermy 1 had very decided views 
of its features, and he described it as follows : 

" Every hysterical woman is stout, short, dark, plethoric, 
full of life and of health. The complexion is brunette and 
ruddy, the eyes black and sparkling, the mouth large, the 
teeth white, the lips of a carnation red, the hair luxuriant 
and of the color of jet, the sexual organs well developed, 
and the spermatic liquid abundant." 

Aside from his physiological error relative to the sper- 
matic liquid, these are the characteristics of the women of 
the south of Europe. If he had lived in the north, where 
hysteria is fully as common, he would have found that his 
description of the hysterical temperament would not have 

1 Quoted by Briquet, Traite Cliniaue et Therapeutique de l'Hysterie, Paris, 
1859, p. 91. 



HYSTERIA. 621 

held good. Indeed, Sydenham, Whyte, Copland, and other 
English authors, represent the hysterical predisposition with 
almost the very opposite characteristics. As Briquet l re- 
marks, there is no hysterical constitution appreciable by the 
study of external appearances. The disease takes women 
as it finds them, blondes, brunettes, stout, thin, strong, 
weak, ruddy, or pale, there is no choice. Some hysterical 
women have delicate figures, and intelligent minds, but 
there are others whose dull, stolid faces give evidence of 
their stupidity ; and others, again, whose thin, fleshless, and 
wan faces, tell us that the Greek type of female beauty is 
not to be regarded as predisposing to the development of 
hysteria. 

While, therefore, admitting the existence of the hysteri- 
cal diathesis, I know of no marks by which its presence can 
be determined, other than the acts of the patient, which go 
to make up the clinical history. 

Mental Symptoms. — These are very various, but gener- 
ally consist in emotional disturbance, an inability or indis- 
position to exert the will, and in the existence of illusions, 
hallucinations, or delusions. Attacks are often character- 
ized by no other prominent symptoms than those connected 
with mental action, and they may assume every possible 
character. At times, the patient is depressed in spirits, 
and sheds tears profusely ; a few minutes afterward, she 
has forgotten her grief, and laughs immoderately, without 
adequate cause. Sometimes she laughs and cries at the 
same time. 

Or, there may be a total insusceptibility to any emotion, 
a listless insouciance, which contrasts strongly with her 
natural disposition. Or, again, an emotion the exact oppo- 
site of the proper one is excited. This is quite a common 
form of manifestation. A mother, for instance, is informed 
that her daughter has contracted an improper marriage, 
and is immediately seized with immoderate laughter, and 
1 Op. cit, p. 92. 



622 CEREBROSPINAL DISEASES. 

shows every expression of pleasure, when the rest of the 
family are overwhelmed with grief and shame. Another 
draws the chief prize in a lottery, and begins at once to cry 
and wring her hands. A third, hearing that burglars have 
entered the house and have stolen all her jewelry and 
silver, sits stolidly in her chair, her hands folded in her lap, 
and her whole expression indicating the most complete 
indifference. During either of these conditions, she may 
be entirely silent, or excessively voluble, or she may exhibit 
other hysterical phenomena. 

As regards the will, the manifestations of disorder are 
sometimes very remarkable. That the patient is, for the 
time being, unable to exert it, is evident, but, under the 
influence of some strong exciting cause, she frequently 
astonishes those about her by suddenly reacquiring her lost 
volitional power. 

A young lady came under my charge for what was sup- 
posed to be a disease of the spinal cord. She had taken to 
her bed suddenly, soon after striking her back rather gently 
against the edge of a table, declaring that she could not walk. 
On examination, I was convinced that there was no disease 
whatever of the spine, other than that of a purely hysterical 
character, and I so expressed myself to her. She, never- 
theless, insisted upon it that her spine was seriously injured, 
and she continued to keep her bed, lamenting daily her sad 
fate at being compelled to pass so long a time shut out from 
the enjoyments of life. There was no paralysis or even 
simulation of it, for she moved her legs about freely enough 
in the bed. But, one evening, her brother, who had long 
been absent, returned home. She heard the bustle in the 
house attendant upon his arrival, but all were too busy to 
pay any attention to her in her chamber up-stairs. Sud- 
denly exclaiming, " I can stand this no longer," she sprang 
from her bed, rang for her maid, and, hurrying on her 
clothes, proceeded down- stairs and entered the drawing- 
room, to the great surprise of all the family. 



HYSTERIA. 623 

In another case, a lady closed her eyes, and declared that 
she could not open them. She was brought to me as a case 
of double ptosis. There was no spasm of the orbicularis pal- 
pebrarum on either side, and I had no difficulty in opening 
the eyes by gently raising the lids. The pupils were normal ; 
there was no diplopia, and there were no evidences of such 
cerebral lesions as are generally met with as causes of ptosis. 
Moreover, she was subject to paroxysms of hysterical syn- 
cope. Under the circumstances, I had no hesitation in 
expressing my opinion to her friends that the case was one 
of hysteria. I advised the use of the induced current to 
the eyes, and she found this so disagreeable, not to say 
painful, that two applications were sufficient to restore her 
volitional power, so that she opened her eyes without diffi- 
culty. 

In my remarks on aphasia, I have cited a case (p. 166) 
in which the power to speak suddenly returned under the 
influence of excitement, and was as suddenly lost again, to 
be gradually recovered. 

Many cases of this loss of volition in hysteria have been 
under my care, and most physicians have witnessed similar 
instances. 

Illusions are very common phenomena of hysteria, and 
these may be connected with any or all of the senses. A 
ball rolling over the floor is taken for a rat; the sound of 
rain falling on the roof is mistaken for the noise of burglars 
in the next room; the knives used at table all smell 
" fishy ; " every thing tastes sour or bitter or sweet, as the 
case may be, and a draught of cold air on the hand is sup- 
posed to be the touch of a person or a spirit. 

Hallucinations of various kinds are equally frequent. 
Images are seen where there is nothing ; voices are heard 
where there is absolute silence; odors are smelt where there 
is nothing to smell ; and strange tastes are perceived when 
the mouth is empty. 

Thus one patient sees angels, another demons, another 



624 CEREBROSPINAL DISEASES. 

animals of various kinds. One hears voices whispering to 
her, another musical sounds, and another noises like the 
breaking of glass or dishes. Another is constantly sensible 
of a smell as if something is burning, and another always 
has a taste of turpentine in her mouth. 

It is not often the case that these erroneous perceptions 
impose on the intellect, but sometimes they do, and then 
delusions are entertained, or these may, as in cases of abso- 
lute insanity, be formed without the intervention of the 
deranged perceptive faculties. They differ, however, from 
the delusions of insanity, such as have been already de- 
scribed, in the facts that they do not last long, and that 
they rarely exercise any very powerful influence over the 
actions of the patient. 

Besides these mental phenomena indicative of cerebral 
disturbance, there are, sometimes, an extraordinary acute- 
ness of understanding and readiness at reasoning and 
speech quite beyond the natural powers of the patient. At 
other times, on the contrary, the intellect is dulled, and the 
conversational power reduced to a low point. 

Sensibility. — This may be affected so as to result in the 
production either of hyperesthesia or ancBsthesia. 

Hyperesthesia, caused by hysteria, is characterized by 
the facts that it is never permanently fixed in one place, 
that it is generally excessively acute, and that it is unac- 
companied by evidences of serious disease of the nervous 
centres or the nerves. A common seat is the skin, and its 
favorite regions are the trunk, especially the skin over the 
mammary glands, and that covering the labia majora. An- 
other situation frequently affected is the skin of the face. 

Cutaneous hyperesthesia may consist either of sponta- 
neous pain or of tenderness to impressions made upon the 
surface of the body. Muscular hyperesthesia, or myalgia, 
is likewise common. Dr. Inman 1 has investigated this 
branch of the subject very carefully, and has ascertained 

1 On Myalgia : its Nature, Causes, and Treatment, etc. London, 1860. 



HYSTERIA. 625 

that the painful spots correspond to the origins and inser- 
tions of the muscles. 

Muscular pains due to hysteria are often mistaken for 
pains of the viscera. Thus the headache which is so fre- 
quent a phenomenon of the hysterical condition is very 
seldom located within the cranium. It may be of very lim- 
ited extent, constituting the form known as the clavus hys- 
tericus, or may be of more extensive limits. Its ordinary 
situations are the frontal regions, occupying, in this case, 
the occipito-frontalis and corrugator supercilii muscles ; the 
temporal regions, being then located in the temporal mus- 
cles ; the vertex, being then seated in the tendon of the 
occipito-frontalis muscle ; and the occipital region, in the oc- 
cipito-frontalis, trapezius, splenitis and complexus. Briquet 
states that, of three hundred and fifty-six hysterical patients 
whom he questioned on the subject, three hundred were 
constantly subject to headache. I have very rarely met 
with a case of hysteria in which it was not constantly pres- 
ent, and never one in which it was not a symptom at some 
time or other. 

Pains are often felt in the muscles of the chest, abdomen, 
and back. This latter is a favorite situation, especially in 
the region between the shoulders, and in the muscles on 
each side of the vertebral column in the lumbar region. 

Pains in the joints are common manifestations of hys- 
teria, and they are often mistaken for serious organic dis- 
ease. When, as is sometimes the case, they are accompa- 
nied with contractions of the muscles, the liability to error 
on the part of the practitioner is increased. Sir Benjamin 
Brodie, 1 several years ago, pointed out the true nature- of 
certain affections of the joints occurring in hysterical women, 
and, since his time, others, among whom Barlow 2 and Skey 3 

1 Illustrations of Certain Local Nervous Affections. London, 1837. 

2 A Treatise on Diseases of the Joints. London. 

3 Hysteria, etc. Six Lectures delivered to the Students of St. Bartholo- 
mew's Hospital, 1866. London, 1867. 

40 



626 CEREBROSPINAL DISEASES. 

are to be mentioned, have called special attention to the sub- 
ject The pain may be attended with swelling, but there is 
no accumulation of fluid in the cavity of the synovial mem- 
brane. The knee is more frequently affected than any other 
joint. 

Neuralgia often has an hysterical origin, and may be in 
the form of toothache, pleurodynia, sciatica, or pain in the 
course of- any other nerve. The viscera are likewise fre- 
quently hypersesthetic ; the stomach, bowels, the kidneys, 
bladder, uterus, and ovaries, are the organs most frequently 
affected. 

The organs of the special senses rarely escape having 
their sensibility exalted, and, consequently, there are in- 
creased power of vision, morbid acuteness of hearing, and 
an abnormal sensitiveness of the smell and taste. Sometimes 
with these hypersesthetic conditions there is pain. 

Ancesthesia. — Though not so common as hyperesthesia, 
anesthesia is frequently a manifestation of hysteria. Its 
most common seat is in the skin. In the days of witch- 
craft, many an hysterical woman, with anesthetic spots on 
her skin, went to the gallows or the stake on suspicion of 
being leagued with the devil. The belief was that, wher- 
ever the hand of the arch-fiend or his assistants touched the 
skin, the spot at once lost its sensibility. 

Two patients are now under my charge in whom there 
is hemi-anesthesia, paroxysmal in its character. When it 
is at its height, no irritation applied to the skin is felt, not 
even the wire brush of a powerful induction-coil. In 
neither case are the attacks preceded or accompanied by 
numbness. 

Sometimes the location is very limited, and the loss of 
sensibility may be partial or complete. In the former case, 
there is numbness, and the full extent can only be exactly 
ascertained by the esthesiometer. 

The mucous membranes may become anaesthetic. The 
one most frequently affected is that which lines the genital 



HYSTERIA. 627 

canal. In such a case, the sexual passion is entirely extin- 
guished, coition is unattended with pleasure, and may even 
excite disgust. 

The organs of the special senses may be the seat of an- 
aesthesia, and thus blindness, deafness, loss of the senses of 
smell and of taste, may be caused, more or less complete in 
character, in different cases. 

Anaesthesia of the muscles is occasionally met with, and 
has, at times, been the occasion of much discussion in medi- 
cal and theological circles. Many of the phenomena ob- 
served in the Jansenist convulsionnaires were the result of 
muscular anaesthesia. In an essay 1 recently published, I 
have called attention to the symptoms, and have adduced 
several cases from the records of my own experience. The 
extent of the anaesthesia is sometimes remarkable. In some 
of the cases that have been under my care, the most power- 
ful induced currents which it was safe to use failed to cause 
pain in the muscles to which they were applied. 

Alterations of Motility. — These may be evidenced in the 
way of paralysis or of clonic or tonic spasm. 

Hysterical paralysis has long been known, and is quite a 
common manifestation of the affection. It may appear in 
the character of hemiplegia, paraplegia, or of much more 
restricted extent. I have a case, now under care, in which 
it is limited to the index-finger, and I have had several in 
which a single muscle of the eyeball, or in which the 
levator palpebrae superioris, was alone affected. 

Hysterical aphonia is due to paralysis of one or more 
muscles of the larynx. Like the loss of power in other 
muscles from a similar cause, it often comes on very sudden- 
ly, and as suddenly disappears. 

Paraplegia, hysterical in its character, may be partial or 
complete as regards a muscle, group of muscles, or a limb. 
When incomplete, the patient, if it involves the lower 
extremities, drags her limbs sluggishly along, or shuffles 

1 The Physics and Physiology of Spiritualism. New York, 1871. 



628 CEREBROSPINAL DISEASES. 

her foot over the floor, using a cane or crutches, or holding 
on to articles of furniture that may be in the room. There 
is nothing about the gait like that of locomotor ataxia or, 
in fact, of any other of the diseases of the cord already 
considered ; and careful observation will generally reveal 
the fact that, during one interview and examination, the 
patient walks very unequally, according to the state of her 
mind at the time, or the influences which act upon her. 

Spasms may be either tonic or clonic, and may affect 
any muscle of the body. In the pharynx, tonic spasm causes 
the sensation to which the term globus hystericus is applied, 
and which gives rise to the sensation of a ball in the throat. 
In the oesophagus, spasm may continue for a long time, and 
may thus simulate stricture. It may also be seated in the 
stomach, intestines, or bladder. 

In the limbs spasm of the tonic character causes con- 
traction, and thus, especially when combined with paralysis, 
may give the appearance of organic lesion. I have fre- 
quently known hysterical contractions to last several months 
at a time, and have had many cases of the kind under my 
charge in which the actual cautery had been applied to the 
back for supposed inflammation of the cord. 

Clonic spasms simulate chorea. They are especially 
common among the women who attend spiritualistic gath- 
erings, and indeed I have seen several cases at such places 
among the weak-minded men who believe in the nonsense 
called spiritualism. 

The functional actions of the viscera are exceedingly 
liable to derangement in hysteria. Any organ of the body 
may be affected, but the stomach appears to be the favorite 
one. There may be obstinate vomiting, or persistent flatu- 
lence, or acidity, or indigestion in some other form ; or 
the bowels may be the seat, giving rise to intestinal indiges- 
tion, diarrhoea, or obstinate costiveness; or the kidneys may 
be involved, and there may be an enormous secretion of 
pale, limpid urine, or the quantity may be reduced to a 



HYSTERIA. 629 

minimum ; or the uterus or the ovaries may be the seat. 
Not infrequently organic disease of the heart is simulated, 
there being palpitation and general irregular action of this 
organ. 

Besides these several manifestations of hysteria, there 
are paroxysms of the disease, characterized by emotional 
disturbance, spasm, convulsions, partial loss of conscious- 
ness, and sometimes coma. All these phenomena may be 
manifested during an attack, or a seizure may consist of any 
one or more of them. The convulsions sometimes bear a 
resemblance to epilepsy, sometimes to tetanus, sometimes to 
hydrophobia, sometimes to catalepsy, sometimes to chorea. 
But, though simulating these diseases, the hysterical parox- 
ysm can be readily distinguished from either of them, mainly 
by the facts of its lack of consistency, the absence of the 
constitutional disturbance which attends the others, and by 
the presence of emotional excitement, and the consequent 
irrational laughing or crying. 

Mania may be simulated, but the false can scarcely be 
mistaken for the real disease by any practitioner with his 
wits about him. 

Causes. — Of the predisposing causes, sex stands first. 
During the last six years three hundred and thirty-two 
cases of hysterical disease have been under my charge or 
been seen by me in consultation. Of these, three hundred 
and twenty-nine were females. Of the three males, one was 
a young gentleman, the son of a distinguished citizen of 
Virginia, in whom the affection was induced by excessive 
study. One was a lawyer in this city, the disease in him 
simulating epilepsy ; and the third was a shop-keeper from 
JSTew Jersey, who had tetanoid paroxysms attended with fits 
of sobbing, crying, and laughing, and in whom it was ex- 
cited by masturbation. 

But, while there is this great predominance of females 
as the subjects of hysteria, I do not believe that the fact is 
due to any particular influence of the uterus or other gen- 



630 CEREBROSPINAL DISEASES. 

erative organs. It is probably the result of the delicacy of 
organization, and the greater development of the emotional 
system, acted upon by the exciting causes to be presently 
mentioned. 

Age is another predisposing cause. The period of life 
at which hysteria is most common is that extending from 
sixteen to twenty-five. After the latter age there is a grad- 
ual decline until the age is reached at which the menstrual 
function begins to become irregular, and then the number 
of cases increases. 

The civil condition, as regards marriage or celibacy, is 
to be taken into consideration among the predisposing 
causes. Undoubtedly the disease is much more frequent 
among the single than the married, but it is by no means 
confined to them. In my opinion the increased proclivity 
of single women to hysteria is not to be attributed to un- 
gratified sexual desires, or even to the non-fulfilment of the 
functions of the generative organs, but rather to that lack 
of aims in life, and the consequent reflection of the thoughts 
and emotions upon self, which are so inseparably connected 
with the present condition of single women. Certainly 
those celibates who have made for themselves objects in 
existence are no more subject to hysteria, in my experience, 
than married women. . Want of occupation is one of the 
powerful predisposing causes of hysteria, and it is to a great 
extent through the direct influence of this factor acting 
upon a more impressionable organization that, in my opin- 
ion, hysteria is more common in women than in men. In 
those savage and semi-savage countries where women work, 
hysteria is unheard of. It used to be almost unknown 
among the negro women in the South, but since their 
emancipation, if my inquiries have ascertained the truth, 
it is becoming quite common among them. 

Hereditary influence is undoubtedly an important pre- 
disposing cause of hysteria. My own statistics are not 
complete on this point, but of the two hundred and nine 



HYSTERIA. 631 

instances in which I have made the inquiry, one hundred 
and thirty-one had either hysterical mothers, aunts, or grand- 
mothers, and many of the others had relatives affected with 
other nervous diseases. Briquet speaks very emphatically 
of the decided influence of hereditary tendency as deduced 
from his inquiries. 

The luxurious habits of life attendant upon refinement 
and education conduce to the development of hysteria. At- 
tendance at theatres and operas, the cultivation of music, 
the reading of poetry and novels, the study of art, and any 
other influence capable of developing the emotional system 
at the expense of the purely physical or intellectual, favor 
the growth of hysterical tendencies. 

Of exciting causes, sudden emotional disturbance ranks 
first. Anxiety, grief, disappointment, the intense desire of 
self-gratification, a fit of ill-temper, with other similar fac- 
tors, often induce paroxysms of the disease. Mental or 
physical fatigue, menstrual derangement, or uterine or ova- 
rian difficulties, may also act as exciting causes. 

But probably, above all these, is the contagion set in 
action by the contact with an hysterical person. I have seen 
a whole hospital ward of women thrown into paroxysms of 
hysteria by one patient suffering from an attack. 

Diagnosis. — To detail the diagnostic marks which distin- 
guish hysteria from other diseases would require more space 
than is proper in a work like the present, and would, more- 
over, be rather a work of supererogation. The physician 
has simply to recollect that all hysterical affections have a 
family resemblance, and that, although almost every known 
disease may be simulated, yet that the counterfeit is never 
a good one. Attention to the symptoms of the several dis- 
eases already and to be described, with a careful observa- 
tion of the case, and due inquiry into the antecedents of the 
patient, will prevent a mistake being made. 

He must also recollect that the hysterical patient always 
tries to impress others with the belief that she is very ill. 



632 CEREBROSPINAL DISEASES. 

She craves sympathy, and feeds on it with the effect of 
nourishing her disease. If she can deceive her medical 
attendant by appealing to his kindly emotions, she will do 
it, but failing in this she will try her power over his fears, 
and will leave no stone unturned to deceive him. Careful 
watching, with thorough skepticism, will either result in 
her detection, or in her defeat from sheer weariness. 

Prognosis. — As regards the prospect of recovery from 
any particular manifestation of hysteria, or from a parox- 
ysm of any kind, the prognosis is favorable, provided proper 
treatment be employed, but, as regards the liability to 
further attacks, much depends on the circumstances which 
surround the patient and the time during which she has 
been subject to the affection. If she can be submitted 
to proper treatment, without the interference of herself or 
her friends, the prospect of recovery, even in bad cases, is 
good; but if she is to be allowed to do as she pleases, or 
if injudicious friends are constantly lavishing the sympathy 
and mistaken kindness which keep her disease alive, there 
is not much use in medicine or hygiene, and, as Reynolds 
says, the "case is hopeless, and might as well be left 
alone." 

Morbid Anatomy and Pathology. — Hysteria contributes ab- 
solutely nothing to the science of morbid anatomy. The 
brain, the spinal cord, the sympathetic nerve, give no evi- 
dence of its former presence. It is true, hysteria very 
rarely causes death, but hysterical patients have died of 
intercurrent affections, and post-mortem examinations have 
been made, and nothing which could reasonably be regard- 
ed as the essential cause of the disease has been found. 
Several of the older writers imagined that they had discov- 
ered the lesion in the genital organs, in the stomach and 
intestines, in the brain, and even in the spleen ; but modern 
research teaches us differently. At present, then, we are in 
total ignorance of the character of the lesion. From the 
symptoms, which are so obviously indicative of disordered 



HYSTERIA. 633 

brain and spinal cord, I have felt myself justified in classing 
it provisionally at least among the cerebro-spinal diseases. 

The pathology or morbid physiology of hysteria is be- 
ginning to be better understood as our knowledge of the 
cerebral and spinal actions becomes more complete. Look- 
ing at the brain as a complex organ evolving a complex 
force — the mind — we can understand the possibility of cer- 
tain parts of it becoming disordered, as regards excess, dimi- 
nution, or quality, in the results of their actions. We have 
seen, under the head of insanity, that the mind is made up 
of certain sub-forces — the perception, the intellect, the emo- 
tions, and the will — and that these, when disordered, consti- 
tute varieties of insanity, which are easily recognized. 

Hysteria essentially consists in the predominance of the 
emotions over the intellect, and especially over the will, 
and this exaltation may be so intense as to interfere with 
the sensibility of various parts of the body, or to derange 
the contractility of muscles. 

At the same time, in the paroxysms of the disease, the 
reflex and automatic functions of the spinal cord are in- 
volved to a great extent. 

We daily witness examples of the influence of emotions 
on sensibility and motility. Fear renders the sensibility 
more acute and produces trembling, which is simply clonic 
spasm ; grief causes tonic contractions of the muscles ; sur- 
prise, terror, or horror, paralyzes them ; joy or anger de- 
stroys sensibility to pain, and so on. 

At the same time that there is this exaltation of emo- 
tional power in hysteria, the power of the will is not only 
relatively but is absolutely diminished. The two factors, 
acting together steadily and persistently, induce many of 
the manifestations of hysteria. The disease is, therefore, a 
partial insanity — an insanity, however, in which the patient 
does not entirely lose the power of control, and which is 
capable of being overcome by the voluntary effort of the 
patient, provided a sufficient stimulus to normal volition 



634: CEREBROSPINAL DISEASES. 

be brought to bear. It thus happens that, through the 
influence of such stimulus, every symptom of hysteria dis- 
appears as if by magic. 

The spinal cord is often secondarily affected, and it is 
likewise frequently primarily involved. The gray or the 
white substance, the posterior or the antero-lateral columns 
may be implicated, the symptoms varying accordingly. 
Through the spinal cord, in its abnormal condition, we have 
the convulsions of various kinds, the spasms, contractions, 
and the paraplegic phenomena connected with motion and 
sensation. 

As to the influence of the vaso-motor system, though I 
admit its existence, I am convinced that it it is simply a 
link in the chain, and is secondary to the emotional disturb- 
ance already mentioned. 

Treatment. — E"o cases are so well calculated to test the 
patience and tact of the physician as those of hysteria. 
For he has an affection to deal with which not only requires 
proper medical treatment, but in which he must often exert 
the highest mental qualities, in order to cure the disease. 
A great deal, therefore, depends on the knowledge of human 
nature and the force of character of the physician ; and it is 
doubtless owing to this fact that some physicians, with all 
their medical knowledge, fail in curing hysterical affections, 
while others, with no superior science, succeed at once. 

The first thing to be done is to gain the confidence and, 
what is of still greater importance, the respect of the patient. 
Having done this, any treatment, moral or medical, calcu- 
lated to relieve her, will be much more apt to produce the 
desired effect. 

During the period between the paroxysms, the treatment 
must be directed mainly against symptoms. If the pa- 
tient can be made to believe that her case is thoroughly 
understood, that she is not suspected of shamming, and that 
with her assistance the hyperesthesia, or anaesthesia, or 
paralysis, will be removed, the effect which is desired will 



HYSTERIA. 635 

probably be produced. For putting an hysterical patient 
into a proper frame of mind, I know of nothing equal to 
the bromides, of either potassium or sodium, given in large 
doses, repeated three or four times a day, till the full effect 
is obtained. This, of itself, will generally relieve hyperes- 
thesia wherever it may be seated, and the influence over 
the mental phenomena of the disease is usually very decid- 
edly shown. 

If anaesthesia be the prominent condition, electricity is 
to be used, and it is almost a specific. I have never seen a 
case of hysterical anaesthesia resist it. A few days ago, I 
was consulted by a young lady who was entirely anaesthetic 
over the whole of the surface of one side of the body, and 
who had suffered for several weeks. Three applications of 
the induced current through the wire brush, which was 
passed, at each secmce, over the whole anaesthetic region, 
entirely cured her. 

For hysterical paralysis, strychnia and phosphorus are 
the best internal remedies. They may be taken together in 
the form recommended on page 58, and rarely fail to pro- 
duce a cure. Their effect is, however, greatly increased by 
the use of electricity, both of the primary and induced 
forms — the first being applied to the spine, and the latter 
to the paralyzed muscles. 

In cases of spasm, I prefer the bromides, internally, and 
the primary galvanic current, applied to the contracted 
muscles. 

Yisceral derangements are best treated by strychnia and 
phosphorus, as recommended for paralysis. Counter-irrita- 
tion, in the form of blisters, is almost always of service. 
For gastric difficulties, the subcarbonate of bismuth, in 
doses of fifteen or twenty grains, after each meal, will gen- 
erally prove of service. In a very obstinate case of hysteri- 
cal vomiting, recently under my charge, every thing failed 
but hydrocyanic acid. 

Hysterical paroxysms are best treated with ether or chlo- 



636 CEREBROSPINAL DISEASES. 

roform, administered by inhalation. Recently I have re- 
peatedly used the hydrate of chloral, but it has not in my 
hands been as speedy or as effectual in its action as either of 
the other agents. I give them to the extent of producing 
complete insensibility, and repeat them again and again, if 
there are any evidences of a return of the seizure. Whether 
in the purely emotional paroxysms or those characterized by 
muscular spasms of various kinds, or any possible combina- 
tion, nothing is equal, according to my experience, to ether 
or chloroform by inhalation. I have tried every other 
known means, from cold water, dashed in the face, to moral 
suasion, and none of them are comparable to ether or chlo- 
roform. 

But, for the dissipation of the hysterical tendency, long- 
continued treatment is necessary. Medicines which are 
ordinarily regarded as antispasmodics, such as valerian, 
assafoetida, musk, and the like, I have never seen produce 
any benefit in any form of hysteria, and, for the purpose of 
causing any radical change in the organism, they are worse 
than useless. As medicines for this object, I know of 
nothing superior to phosphorus, in some one of its forms, 
and strychnia. They should be taken for months in small 
doses, and should be supported by all hygienic measures cal- 
culated to improve the tone of the system. Travel is of ines- 
timable advantage, and, above all, association with persons 
of both sexes, whose intellects control their emotions, and 
who are endowed with sound common-sense and that tact 
and knowledge of human nature which, for the purposes of 
every-day life, are of more value than many other qualities 
often ranked above them. 

It is, perhaps, scarcely necessary to state that the society 
of other hysterical persons must be rigidly eschewed, and 
that even the casual meeting with such individuals is dan- 
gerous. 



CHAPTEE VII. 

MULTIPLE CEREBRO-SPINAL SCLEROSIS. 

We have already considered the subject of sclerosis as 
it affects the brain and spinal cord separately. We have 
still to treat of it as existing in these nervous centres simul- 
taneously. Although recognized, over thirty-five years ago, 
by Cruveilhier and Carswell, it is only recently, mainly 
through the observations of Charcot and Yulpian, that 
attention has been again directed to sclerosis of the cerebro- 
spinal variety, a form which differs from those already de- 
scribed in this treatise, both in its extent and in the symp- 
toms by which it is characterized. 

Symptoms. — The initial symptoms vary according as the 
morbid process begins in the brain or spinal cord. In the 
former case, the first prominent manifestation of disease 
may be an epileptic fit. In other cases, there are headache, 
vertigo, ocular troubles, such as ptosis, diplopia, or ambly- 
opia, failure of the hearing, and, very often, defective articu- 
lation. The mind does not participate to any considerable 
extent, unless the hemispheres be involved in the lesion. 

Or, there may be hemiplegia as a consequence of cere- 
bral congestion, and even mania, from a like cause. These 
attacks are sometimes frequent, and usually leave more or 
less mental weakness after them. 

Tremor is often first seen in the tongue, more frequently 
in the eyeball, of one or both sides, which oscillates when 
the patient is told to turn it inward or outward, but which 
is steady when he looks directly to the front. This tremor 



638 CEREBROSPINAL DISEASES. 

is called nystagmus, and is, as we have already seen, met 
with in other diseases of the nervous system. 

Tremor is indicative of loss of power, and it gradually 
becomes more strongly marked and extends to other mus- 
cles of the body as other parts of the cerebro-spinal system 
become involved. It is never, however, a constant phenom- 
enon in any form of sclerosis affecting the spinal cord alone. 
Its presence is peculiar either to cerebral disease or to 
lesions occurring at the same time in the brain and spinal 
cord. 

After a time, which is subject to great variation in dif- 
ferent cases, the loss of power extends to the limbs, and 
this feature is often accompanied with aberrations of sensi- 
bility. If, as is generally the case, the membranes of the 
cord are congested or inflamed, there are spasmodic jerk- 
ings or twitchings of the limbs, but in some cases these are 
never observed. In the case of a gentleman from South 
Carolina, who consulted me at the instance of my friend 
Dr. Darby, of that State, and who was obviously affected 
with multiple cerebro-spinal sclerosis, there had never been 
the slightest involuntary movement, independent of the 
peculiar form of tremor in the limbs which constitutes so 
prominent a feature of the disease. 

The lower extremities are generally very much more 
paralyzed than the upper, and, when they become involved, 
festination often makes its appearance. The gait of the 
patient, thus, becomes similar to that of a person in whom 
the lesion is limited to the brain. 

If the sclerosis begins in the brain before attacking the 
spinal cord, tremor precedes the paralysis — the affection 
being then entirely cerebral in character; but, when, as is 
generally the case, the lesion appears primarily in the spinal 
cord, paralysis is noticed before the tremor. In fact, there 
is never, as previously insisted on in my remarks on multiple 
cerebral sclerosis, any tremor, unless the superior ganglia of 
the cerebro-spinal system are involved. The fact that it is 



MULTIPLE CEREBRO-SPINAL SCLEROSIS. 639 

only shown when a voluntary movement is made also assists 
us to distinguish it from the tremor of multiple cerebral 
sclerosis, as well as from that of paralysis agitans. In the 
cerebro-spinal form of the disease, therefore, the patient re- 
mains without tremor so long as he is quiescent. But, if he 
attempts to cross one leg over the other, or to carry a glass 
of water to his lips, the extremity executing the movement 
is at once seized with tremor, and the act is performed with 
great difficulty. 

The ability to place the fingers on any part of the body, 
unassisted by the eyesight, is impaired, as in the cerebral 
form of the disease, and in sclerosis affecting the posterior 
columns of the spinal cord. 

As the disease advances, the paralysis becomes more 
strongly marked ; the limbs are permanently contracted ; 
the bladder loses its expulsive force ; its sphincter no longer 
completely closes the orifice ; the bowels become obstinately 
constipated, and there is a strong tendency developed to the 
formation of bed-sores. The head-symptoms likewise in- 
crease in intensity, but the mind remains clear to the last 
in the great majority of cases. Indeed, my observation of 
many cases has convinced me that in the cerebro-spinal 
form of sclerosis the hemispheres are not often involved, 
even when the disease has lasted several years. 

The difficulties of articulation notably increase, and the 
muscles of deglutition likewise become involved. In con- 
sequence, the saliva is not swallowed as often as it should 
be, and it therefore dribbles from the mouth. Mastication 
is difficult, and the facial muscles gradually become in- 
volved. The countenance of the patient at this period is 
not unlike that of a person suffering from glosso-labio-laryn- 
geal paralysis, as in fact might be expected, the same nerves 
and muscles being involved. Finally, the patient dies from 
exhaustion, or from some intercurrent disease. 

Few diseases are so irregular and un uniform in their 
phenomena as the cerebro-spinal form of sclerosis. This 



640 CEREBROSPINAL DISEASES. 

is due to the fact that the organs liable to be the seat of 
the disease are numerous and of varied functions. The es- 
sential features of the affection are tremor occurring gener- 
ally after paralysis, and only manifested during the perform- 
ance of voluntary movements. It is not always necessary, 
however, that the movements should be of the partially- 
paralyzed limbs, for I have seen cases in which tremor was 
excited in a paretic leg by the act of executing voluntary 
movements with a sound hand. 

The following histories will contribute to a fuller under- 
standing of the subject : 

Cruveilhier * reports the case of a cook, aged thirty-seven, 
who six years before coming under observation noticed that 
he was losing power in the left leg, so that he nearly fell in 
the street. Three months subsequently the right leg be- 
came similarly affected, and then the superior extremities 
followed. They were tremulous and weak, but the patient 
was still able to use them to some extent. The sensibility 
remained intact, and the reflex faculty of the cord was un- 
impaired. In other respects the patient was condemned 
to immobility. There were no spasmodic retractions of the 
limbs, and no painful contractions. The articulation was 
imperfect, but the intelligence was unaffected. There ap- 
pear to have been no marked head-symptoms in this case. 
" Point de cephalalgie jamais de cephalalgie, le malade en- 
tendait a merveille." After death there was found gray 
degeneration of the spinal cord, of the medulla oblongata, 
of the pons Varolii, of the right cerebral peduncle, of the 
right optic thalamus, of the corpora callosa, and of the for- 
nix. The hemispheres were not involved. 

Two other cases, similar in general character to the fore- 
going, are given, in neither of which were the hemispheres 
involved. 

Another case, that of Josephine Pajet, is cited by Cru- 

1 Anatomie pathologique du corps hunlain, Paris, 1835, 1842, t. ii., liv. 
xxxii., Fig. 4, PI. II. 



MULTIPLE CEREBROSPINAL SCLEROSIS. 641 

veilhier. 1 In this there was almost complete insensibility 
of the inferior extremities, though the patient was able to 
move the toes, the feet, and the legs. There were no 
cramps and no contractions. There was also diminished 
sensibility of the superior extremities. All the limbs were 
weak, and the arms were affected with tremor. The patient 
could walk and sew when first seen. The right hand was 
stronger than the left. There was a sensation of a tight 
band around the abdomen. After death there was gray de- 
generation of the cord, and of the pons Yarolii. 

In none of these cases were there spasmodic jerkings or 
tonic contractions of the limbs. Two cases have been re- 
ported by Friedreich. 3 In one of these a man, aged twenty- 
one, was the subject. Among the first symptoms were men- 
tal excitement, vertigo, pain in the head, and weakness of 
the lower extremities. The gait was unsteady, and there 
was tremor upon any emotional excitement, or on the at- 
tempt to execute movements. This affected the upper and 
lower extremities, the head and the eyeballs. After death, 
patches of sclerosed tissue were found on the tubercula 
mammillaria, the cerebral peduncles, the pons Yarolii, and 
the medulla oblongata. 

The other case was that of a woman, aged twenty, who 
was attacked, when seventeen years of age, with weakness 
of the right leg. Soon afterward the left became affected, 
and subsequently the arms. These latter were rendered 
tremulous at every attempt to move them. The speech was 
implicated, and there was nystagmus. The mind was weak- 
ened, and the sensibility was impaired. 

In the first of these cases the disease appears to have 
begun in the brain ; in the second, in the spinal cord. 

Vulpian, 3 under a title which goes to show how even the 

1 Op. cit, liv. xxxviii., Fig. 1, PI. V. 2 Deutsche Klinik, No. 14, 1856. 

3 Note sur la Sclerose en Plaques de la Moelle epiniere. L'Uhion Medicale, 
No. 70, Juin 14, 1866, p. 507. Like other writers, Yulpian, in this paper, 
brings together cases which have no affinity except as regards the general char- 
acter of the lesion. 
41 



642 CEREBROSPINAL DISEASES. 

best authorities have confused the whole subject of sclerosis, 
describes an interesting case communicated by Charcot. In 
this instance a woman aged forty-three, of nervous tempera- 
ment, had been subject to frequent attacks of facial neural- 
gia, and had often suffered from vague pains without deter- 
minate seat. In 1856 she suffered from attacks of vertigo, 
which, from being rare at first, subsequently came on five 
or six times a day. Sometimes she fell, but never lost con- 
sciousness, or had any convulsive movement. 

Shortly afterward, during the night, she was seized with 
vomiting, cramps in her limbs, and a numbness of the right 
side. In the morning she was hemiplegic. Fifteen days 
afterward motion reappeared in the arm, but the leg re- 
mained paralyzed. In 1859 she had another attack of hemi- 
plegia, and this time was deprived of speech for fifteen days. 
After this seizure, there were contractions of the flexors of 
the fingers, and of the forearm of the right side. In 1861 
she had a third attack. 

In 1862 (January 1st) she came under M. Charcot's care. 

The intellect ual faculties were not involved. The right 
superior extremity was almost entirely paralyzed, and was 
in a state of rigidity and contraction. The lower extremities 
were permanently extended, and could not be flexed but by 
great effort. Sensibility was perfect throughout, and reflex 
movements could still be excited. She died February 9th. 

On post-mortem examination, patches of sclerosed tissue 
were found in the right middle cerebral peduncle, the pons 
Yarolii, the medulla oblongata, and the cervical region of 
the spinal cord. The hemispheres were perfectly healthy. 

In this case, it is probable that the contractions were 
mainly due to secondary degeneration of the cord, a condi- 
tion which, as we have seen, is analogous to sclerosis. It 
will be observed that there were no tremors, either with or 
without voluntary motions. 

Another important case has been reported by M. Ma- 
gnan : 1 

1 Memoires de la Societe de Biologie, Paris, 1869. 



MULTIPLE CEREBROSPINAL SCLEROSIS. Q±$ 

A woman, aged thirty-four, came under observation in 
July, 1869. In 1848, when thirteen years of age, she 
had an attack of typhoid fever, from which she lost her 
sight. The first symptom of her disease occurred in 1867, 
and consisted of trembling of the hands and arms whenever 
she endeavored to execute any difficult movement. Before 
long, the tremor involved the lower extremities ; but there 
was no paralysis till about eight months previous to her ad- 
mission to the hospital. At this time, every effort at motion 
caused tremor. The hands, arms, legs, eyeballs, and even 
the muscles of the trunk were involved. The articulation 
was defective, and there were various painful sensations in 
different parts of the body. Ophthalmoscopic examination 
showed atrophy of the optic disks and nerves. 

The diagnosis in this case was multiple cerebro-spinal 
sclerosis — an opinion which I do not think is warranted by 
the facts. The lesion was probably entirely confined to the 
brain. The main reason which leads me to entertain this 
view is, that the tremor appeared before the paralysis. I 
cite the case for the purpose of showing how little accord 
there is among authors relative to the association of symp- 
toms with lesions in the several forms of sclerosis. 

Eleven cases of the cerebro-spinal form of sclerosis have 
been under my care ; and, though I have not had the oppor- 
tunity of verifying my diagnosis in a single instance, I 
think the symptoms have been of such a character as to 
indicate the existence of the lesion so graphically described 
by Charcot, Friedreich, and Bourneville and G-uerard. 1 
The fact, that several of the histories were written out 
before Charcot's investigations gave me a clew to their real 
import, will tend, I think, to increase their value. 

Mr. M., a gentleman fifty-three years of age, consulted 
me April 8, 1865, at the instance of my friend Prof. For- 
dyce Barker, M. D., for partial paralysis with tremor, mainly 

1 De la Sclerose en Plaques disseminees. Nouvelle IStude sur quelques 
Points de la Sclerose en Plaques disseminees. Bourneville, Paris, 1869. 



$4:4: CEREBROSPINAL DISEASES. 

affecting the right arm and leg. Two years previously he 
had suffered from vertigo and headache, which were followed 
by a slight attack of hemiplegia of the right side, unattend- 
ed by loss of consciousness. He gradually recovered from 
this, but, about six months before he came under my obser- 
vation, he noticed that his right leg began to drag, and, 
soon afterward, that the arm of the same side became weak. 
About the same time he had headache, vertigo, and weak- 
ness of sight. A short time subsequently — about a month 
as well as he could recollect — the arm was seized with tre- 
mor while attempting to carry a glass of wine to his lips. 
The agitation continued to grow more violent on any vol- 
untary movement of the arm, and gradually his speech be- 
came involved. 

"When I saw him he was still suffering from occasional 
attacks of vertigo and headache; the lips were agitated 
whenever he attempted to move them, the tongue was 
tremulous, and his speech was consequently halting and 
jerking. There was also nystagmus, a symptom which he 
had not noticed. 

The right arm was unaffected with tremor so long as he 
allowed it to rest on his knee or to hang by his side ; but, in 
the act of moving it, the whole extremity was agitated by a 
series of short, vibratory motions, consisting of flexions and 
extensions, which continued so long as he persevered in the 
movement, or kept the arm in any position requiring mus- 
cular exertion. The right .leg was weak, and dragged so 
that he struck his foot against any slight obstruction. 
There was a little tremor in it when he attempted to cross 
it over the other as he sat in a chair. 

I treated him solely with the primary galvanic current, 
which I passed through the brain and spinal cord — the first 
time such an operation was ever performed in this country 
for the treatment of disease. My diagnosis was incipient 
softening of the ganglia at the base of the brain and of the 
upper portion of the spinal cord. My opinion was, that the 



MULTIPLE CEREBROSPINAL SCLEROSIS. 645 

hemispheres were not involved, as there were no symptoms 
indicating mental weakness or disturbance. 

I made an application of about fifteen minutes' duration 
every day. He gradually but rapidly improved, and to 
such an extent that on the 19th of April he wrote to me as 
follows : 

" Yesterday must be marked with a white stone as the 
best day yet. Foot active, hand and arm steady, and spirits 
good. If we can manage to fix these good effects, cure is 
certain. 

" I hope the magic pile will be ready to repeat its good 
work on Saturday next." 

He continued to improve for several weeks, then gradu- 
ally went back to his former condition, and from that rapid- 
ly grew worse. The paralysis invaded the other side, then 
tremor followed, the speech became much more difficult, 
and he died in the country two years subsequently. 

Miss H., of Connecticut, aged thirty-five, consulted me 
January 20, 1870, for paralysis and tremor. About two 
years previously, she had noticed a weakness of the right 
arm, which had been preceded by occasional attacks of not 
very severe headache and vertigo. The arm gradually be- 
came weaker, and in the course of a few months began to 
shake whenever she attempted to use it. Before the year 
had expired, the right leg began to drag a little, and lost a 
good deal of its natural strength. Her speech also became 
difficult, not from any failure to remember words, but from 
tremor of the tongue and weakness, with a little rigidity of 
the lips. 

When I saw her, the articulation was halting and syl- 
labic; there was nystagmus in both eyes; the right arm 
was very weak; she could only move the index of my 
dynamometer four degrees, equivalent to a pressure of two 
pounds and a half, while with the left hand she could move 
it twenty-eight degrees. Every attempt to move the arm 
caused trembling of the whole extremity. So long as she 



616 CEREBROSPINAL DISEASES. 

refrained from any exertion of voluntary power, it remained 
free from agitation. She conld not write, owing to the tre- 
mor which the effort to do so excited. There was slight 
tremor in the leg, when she slowly raised the foot from the 
ground. 

The mind was perfectly intact, and she was entirely free 
from any emotional weakness. 

In this lady's case I diagnosticated multiple cerebro- 
spinal sclerosis — the " sclerose en plaques disseminees" of 
Charcot. 

I treated her with the chloride of barium and the pri- 
mary galvanic current. By the following autumn she had 
improved so much that she could walk several miles without 
fatigue, lifted her foot clear of the ground, could move the 
index of the dynamometer to thirty degrees, was free from 
tremor, except when she attempted to write, and then it 
was only manifested to a slight extent. I now ceased using 
the galvanism, but continued the chloride of barium. On 
the 28th of January, 1871, she paid me a visit. She was 
then walking well, but there was still a very slight tremor 
when she attempted to execute delicate or difficult move- 
ments with the right arm. I directed the continuance of 
the barium. 

Mr. H., of South Carolina, a highly-educated and intel- 
ligent gentleman, consulted me, September 12, 1870, for 
paralysis and tremor. As he entered my consulting-room, 
the tendency to festination was exceedingly well marked. 
On examination, I found his mind perfectly clear. There 
were nystagmus and syllabic articulation. On moving the 
left arm or left or right leg, the limb became tremulous. 
There had never been any head-symptoms. 

On the 19th, at my request, he wrote a short account of 
his disease, which I here transcribe : 

" I was never robust in health, but, on the other hand, I 
have never had, since childhood, a serious spell of sickness. 
My manner, of life has been sedentary — that of a student. 



MULTIPLE CEREBROSPINAL SCLEROSIS. 647 

I was always careful not to overtask myself until I became 
engaged, in the year 1864, in a mathematical research. 1 
was for a considerable length of time very much absorbed 
in this work, and allowed it to encroach seriously upon my 
hours of recreation and sleep. 

"In the fall of 1865, after having accomplished the 
above work, I observed a slight lameness in my left foot — a 
tendency to strike the toe against the inequalities of the 
ground — an inability to raise quickly enough 'the front part 
of the foot. 

" After my return home, summer of 1866, from Europe, 
where I had spent five or six years, the lameness in my foot 
increased rapidly, and in the winter of 1866-'67 a lameness 
in my left hand was very perceptible — an inability to move 
the fingers quickly, and a tremor, particularly of the thumb, 
when I attempted to do so. 

" The above symptoms have gradually grown worse, and 
within the last year the right leg has become involved, to 
the extent that it begins to shake when I stand upon it, and 
it shakes even while sitting, when I am under excitement, 
or when I execute difficult voluntary motions with my 
hands. 

" The disease seems to make greater progress in hot 
weather. I have at no time suffered pain, my appetite and 
digestion are good, and I generally sleep well." 

This gentleman improved greatly through the use of the 
primary galvanic current, chloride of barium, and tincture 
of hyoscyamus, during the two weeks that he remained in 
New York under my care. On his return to South Caro- 
lina he took a primary-cell battery with him. 

On the 11th of January, 1871, he wrote to me as fol- 
lows : 

" Sometimes I thought I was improving slowly, or at 
any rate not losing ground, and then again, for several days 
together, I would feel confident that I was falling back. 
But now I think I can certainly say I am growing worse. 



648 CEREBROSPINAL DISEASES. 

All my symptoms have been worse — lamer, more nervous, 
and the disease more general in its effects. My right hand, 
which has heretofore been comparatively unaffected, is now 
seriously implicated, and yet I still manage to write after a 
fashion. I find it very difficult to dress myself, and I must 
make several attempts before I can get up from a sitting or 
a lying posture. 

" "What could have caused the improvement that took 
place while I 'was under your immediate treatment?" 

In this case I diagnosticated multiple cerebro- spinal 
sclerosis, and I think those acquainted with the disease will 
agree with me in my view of the case ; and yet there was 
as strongly-marked festination as I have ever seen. The 
gentleman could trot well, could mount a staircase without 
much difficulty, but walking slowly, or descending stairs, 
troubled him greatly. According to some authors, this 
symptom would, of itself, have been sufficient to contra- 
indicate the existence of sclerosis, and to have placed the 
disease among the neuroses. My views on this point have 
already been expressed under the head of multiple cerebral 
sclerosis. 

J. F., a gentleman of this city, forty-two years of age, 
consulted me November 29, 1870. On the 4th of July pre- 
viously he had indulged rather freely in champagne, and 
the following morning awoke with severe headache, ver- 
tigo, and nausea. Although he recovered from this attack, 
he never felt quite as well as before, and was frequently sub- 
ject to headache and vertigo — symptomatic, as he thought, 
of gastric disorder. About a month after his first symp- 
toms he was suddenly conscious of a singular sensation 
about his left eye, and on looking in the glass discovered 
that the upper lid had dropped, and that he could not raise 
it. This was about five o'clock in the afternoon, and by 
ten that night the lid entirely covered the pupil. The fol- 
lowing morning it was not so low, but he found that he saw 
double. He continued to attribute all his troubles to the 



MULTIPLE CEREBROSPINAL SCLEROSIS. 649 

stomach, and began taking some quack remedy recom- 
mended to him for dyspepsia. 

In the course of a few days, feeling no better, he went 
to the sea-shore, and while there noticed that his right arm 
became weak, and that he frequently let things drop from 
his hand. He had difficulty in shaving and in dressing him- 
self, from inability to coordinate the muscles, and there was 
numbness of the ends of the fingers. During all this time 
he had suffered more or less from headache, vertigo, and 
double vision, and the ptosis still continued. Gradually the 
left arm became involved, and, by the time the paresis in 
this extremity was well established, the right arm was affect- 
ed with tremor, but only when he attempted to execute 
movements with it. Thus, as he said, he could place the 
hand on a table and it would continue perfectly quiet ; but, 
as soon as he took a pen to write, or even endeavored to 
raise the hand from the table, it was seized with tremor. 
The left arm soon became similarly affected, and eventually 
the left leg lost strength and was rendered tremulous by 
any attempt at muscular exertion. He noticed also, what, 
as I afterward learned, his friends had perceived several 
weeks before, that his articulation was imperfect, and that 
it was necessary for him to make a mental effort to talk 
distinctly. 

He returned to the city about the middle of October, 
and employed a " rubber " to restore, as he said, the circu- 
lation to his limbs. Continuing to get worse, he consulted 
me. 

At this time there was festination. The speech was 
syllabic and accentuated, the tongue and lips were paretic 
and tremulous, there was nystagmus in both eyes, ptosis 
and diplopia from paralysis of the left sixth nerve, and 
dilated pupil of the right eye. There were also occasional 
headache and vertigo, but not to the same extent as at first. 

Both arms and the left leg were partially paralyzed. 
He could not raise either upper extremity out from the side, 



650 CEREBROSPINAL DISEASES. 

owing to the complete paralysis of the deltoids, but he could 
flex both forearms, and move his hands and fingers tolerably 
well. There was no tremor while he refrained from using 
them, but the least attempt at voluntary motion excited 
them to agitation. The same was true of the left leg. Ex- 
amination with the ophthalmoscope showed both optic disks 
to be white, and the retinal vessels small and straight. 

With the dynamometer he could only exert a pressure 
of nine degrees with the right hand and eleven with the 
left. The line made with the dynamograph was descend- 
ing, showing his inability to maintain, even for a short time, 
a uniform muscular contraction. 

There was no loss of sensibility, except in the upper ex- 
tremities. He had occasionally suffered from pains in the 
back, about the region of the shoulders. 

The power over the sphincters was intact. 

This gentleman could stand and walk as well with his 
eyes shut as with them open. On rising from his chair, 
which he did with difficulty, he always felt impelled to 
take a few steps forward, which were a stagger rather than 
a voluntary movement. In walking, the body was inclined 
forward, and he went in a kind of jog-trot. 

He attributed his disease to dissipation of all kinds, in 
which opinion I expressed my concurrence. 

Under treatment with galvanism, hyoscyamus, and chlo- 
ride of barium, this patient has improved, but not as yet 
sufficiently to warrant any strong hope of a permanent 
cure. 

A gentleman from the northern part of the State of 
New York consulted me in January, 1871, and again in 
March. His symptoms, though decided, were not very se- 
vere in character. Gradually, however, there had been for 
two years a loss of power supervening in the muscles of the 
right side of the body, and lately ocular troubles had made 
their appearance. Tremor, on making any voluntary move- 
ment, was just beginning to appear when I last saw him. 



MULTIPLE CEREBRO-SPIXAL SCLEROSIS. 651 

Its influence over his handwriting is seen in the following 
fac simile : 

Fig. 28. 

One patient, with multiple cerebro-spinal sclerosis, at- 
tends the out-door department of the New York State 
Hospital for Diseases of the Nervous System. He has 
marked head-symptoms. And another, from Philadelphia, 
who was supposed to be suffering from cerebral disease, con- 
sulted me a few days ago. In this case the affection prob- 
ably resulted from a fall. 

The remaining four cases, two of which are now under 
treatment, do not present any such peculiar phenomena as 
to warrant their histories being given in detail. 

Causes. — Nothing very definite is known of the etiology 
of the affection in question. It probably is induced by 
such causes as give rise to the purely cerebral form of the 
disease. Age does not, however, appear to exercise so im- 
portant an influence. Four of my cases were over fifty 
years, and one of them, the gentleman from Philadelphia, 
was over sixty; six were over forty and under fifty, and one 
was between thirty and forty. All were males but one. 

In two cases, it was apparently caused by excessive 
mental application, in one by anxiety, in one by a fall, in 
two by dissipation. In the remaining five cases I could 
discover no obvious cause. In none of them were there 
rheumatic, syphilitic, or other morbid diathesis. 

Diagnosis. — The facts of the tremor making its appear- 
ance after the paralysis, and of its only — or, at least, with 
rare exceptions, and then only in the latter stages of the 
disease — being manifested when voluntary movements are 
being made, will suffice to distinguish the cerebro-spinal 
form of sclerosis from either of the other varieties. The 
points to recollect are these : that, in simple cerebral scle- 



652 CEREBROSPINAL DISEASES. 

rosis, the tremor appears before the paralysis, and does not 
depend on the voluntary contraction of muscles for its exci- 
tation ; in simple spinal sclerosis there is no tremor at all. 
I have already insisted on these distinctions in my remarks 
on the other forms of sclerosis of the nervous centres. 

Prognosis. — This is very generally unfavorable. In only 
one case have I had reason to expect a cure. It often 
happens that amendment very decided in its character 
takes place soon after the beginning of the treatment with 
galvanism and barium. This has been the case in every in- 
stance of the disease that has been under my charge ; but 
in only one has it been permanent. In those now under 
treatment, there has as yet been no relapse; but the time 
is too short to speak with any confidence in regard to the 
ultimate result. 

Morbid Anatomy and Pathology. — The remarks made under 
this head, when the cerebral and spinal forms of sclerosis 
were being considered, apply to the cerebro-spinal variety. 
Charcot 1 has considered the subject of sclerosis mainly in 
its histological relations. The main points are — -and these 
have already been stated several times — that the morbid 
process essentially consists in hypertrophy of the neuroglia 
at the expense of the proper nerve-substance, and that this 
is a consequence of inflammatory action. In the present 
form of the disease, the sclerosed tissue appears in the form 
of plates or nodules in different parts of the brain and spi- 
nal cord. 

Treatment. — The means which I have found most effica- 
cious have 'been stated in the histories of the several cases 
cited. They consist of galvanism, chloride of barium, and 
hyoscyamus. The galvanism should be passed through the 
brain and sympathetic nerve as recommended under the 
head of multiple cerebral sclerosis (p. 298). In addition, a 
strong current — that from sixty cells — should be passed 

1 Gazette des Hopitaux, Nos. 102, 103, 140, 141, 143, 1868. 



MULTIPLE CEEEBRO-SPIXAL SCLEROSIS. 653 

through the spinal cord, as recommended for antero-lateral 
and posterior spinal sclerosis. 

The chloride of barium should be given in solution in 
water, in doses of a grain three times a day — the hyoscy- 
amus in doses of from one to two teaspoonfuls of the tinc- 
ture. 

I have sometimes given the nitrate of silver in fourth-of- 
a-grain doses, three times a day, and very generally recom- 
mend cod-liver oil with each meal. Occasionally I have 
administered iodide of potassium and the bichloride of mer- 
cury, with the view of counteracting a possible syphilitic 
diathesis. 

Whatever measures are adopted should be continued for 
several months at least, and, if the improvement persists, for 
a much longer period. 



CHAPTEE YIII. 

A THETOSIS. 

Under the name of athetosis ( 'AOeros, without fixed po- 
sition), I propose to describe an affection which, so far as I 
know, has not heretofore attracted the attention of medical 
writers, and of which two cases have come to my knowl- 
edge. It is mainly characterized by an inability to retain 
the fingers and toes in any position in which they may be 
placed, and by their continual motion. From these phe- 
nomena, I have applied the term athetosis to the disease, 
having as yet had no opportunity of ascertaining by post- 
mortem examination the nature of the lesion to which the 
symptoms are due. * 

These symptoms will be evident from the following his- 
tories : 

J. P. P., 1 aged thirty-three, a native of Holland, con- 
sulted me September 13, 1869. His occupation was book- 
binding, and he had the reputation, previous to his present 
illness, of being a first-class workman. He was of intem- 
perate habits. In 1860 he had an epileptic paroxysm, and, 
since that time to the date of his first visit to me, had 
had a fit about once in every six weeks. In 1865 he had 
an attack of delirium tremens, and for six weeks thereafter 
was unconscious, being more or less delirious during the 
whole period. 

1 This patient was several times at my cliniques before the class of the 
Bellevue Hospital Medical College, first in the autumn of 1869 and last in Janu- 
ary, 18T1. 



ATHETOSIS. 655 

Soon after recovering his intelligence, he noticed a slight 
sensation of numbness in the whole of the right upper ex- 
tremity, and in the toes of the same side. At the same 
time severe pain appeared in these parts, and complex in- 
voluntary movements ensued in the fingers and toes of the 
same side. 

At first the movements of the fingers were to some ex- 
tent under the control of his will, especially when this was 
strongly exerted, and assisted by his eyesight, and he could, 
by placing his hand behind him, restrain them to a still 
greater degree. He soon, however, found that his labor 
was very much impeded, and he had gradually been re- 
duced, from time to time, to work requiring less care than 
the finishing, at which he had been very expert. 

The right forearm, from the continual action of the mus- 
cles, was much larger than the other ; and the muscles were 
hard and developed, like those of a gymnast. 

When told to close his hand, he held it out at arm's 
length, clasped the wrist with the other hand, and, then ex- 
erting all his power, succeeded, after at least half a minute, 
in flexing the fingers, but instantaneously they opened again 
and resumed their movements. 

I treated him with galvanism, primary and induced, for 
four months, without notable result. His fits were, however, 
arrested with bromide of potassium. 

His memory began to be impaired soon after his attack 
of delirium tremens, and his intellect was manifestly weak- 
ened when I first saw him. 

January 17, 1871, he entered the New York State Hos- 
pital for Diseases of the Nervous System, when the follow- 
ing points, which I cite from the report of Dr. Cross, the 
Resident Physician, were noted : 

The head is symmetrical, but is peculiar in shape — the 
posterior portion rising to a much higher point than the 
anterior, while the latter slopes downward and forward, 
giving the cranium the form of that of a Flathead Indian. 



656 CEREBROSPINAL DISEASES. 

The special senses are normal. The intellect is somewhat 
impaired, and his ideas are not so vivid at one time as at 
another. His memory is much enfeebled. There is slight 
tremor of both upper extremities, but there is no paralysis 
of any part of his body. There are, however, involuntary 
grotesque muscular movements of the fingers and toes of 
the right side, and these are not those of simple flexion and 
extension, but of more complicated form. They occur, not 
only when he is awake, but also when he is asleep, and are 
only restrained by certain positions, and by extraordinary 
efforts of the will. Thus those of the fingers are arrested 
when the wrist is firmly grasped by a strong hand, or when 
it is less forcibly held in a vertical position. But, if the 
arm be extended horizontally, the fingers at once begin their 
movements. During their continuance the arm is hard and 
rigid, and the calf of the leg is also in the same state of 
tonic spasm while the toes are in motion. The movements 
are somewhat paroxysmal, being worse at times than at 
others. During the remissions the power of the will over 
the muscles is more effective than when the paroxysms are 
at their height. 

Sensibility to touch, pain, tickling, and temperature, are 
normal in all other parts of the body. There is slight trem- 
ulousness of the tongue, but no difficulty of articulation. 
There are no oscillatory movements of the eye-balls (nys- 
tagmus). 

The involuntary contractions of the fingers and toes do 
not take place quickly, but slowly, apparently as if with 
deliberation and with great force. The numbness and pain 
in the arm, hand, leg, and foot, have increased in proportion 
to the increase in the contractions. 

The toes are not involved to the same degree as the fin- 
gers. Position does not, however, afford the same relief to 
them as to the fingers, and the spasms are more tonic in 
character. The muscular development is greater in the 
right arm and leg, from the almost continuous muscular 



ATHETOSIS. 



657 



action. The toes are kept restrained to some extent by the 
boot, but as soon as it is removed they become flexed and 
take on their peculiar movements. 

"When, by a strong effort of the will, he succeeds for an 
instant in arresting the movements in the hand, the little 
finger at once becomes strongly abducted, the third finger 
participates to some extent, the second finger is slightly 
flexed, the index-finger is extended, and the thumb is ex- 
tended to its very utmost. These are the positions in all 
cases in which he succeeds in quieting the actions, and they 
are well shown in the accompanying woodcut (Fig. 29) 
taken from a photograph. 



Fig. 29. 




On account of the severe pain in the whole arm, caused 
by the spasms in the muscles, the patient is at times unable 
to go to sleep until quite exhausted. On awaking, however, 
after a few hours' repose, although the actions have contin- 
ued during his sleep, they are not so severe as at any other 
time through the day or night. This state of comparative 
repose lasts for about half an hour. 

His habits are bad. He boasts that he has often drunk 
as many as sixty glasses of gin in a day, and it is therefore 
doubtful whether the tremulousness observed in the tongue 
42 



658 CEREBROSPINAL DISEASES. 

and the muscles generally is the effect of the disease, or of 
drink, or of both combined. I have never, however, seen 
him drank, or even under the influence of liquor. His 
mental faculties are decidedly more obtuse than when he 
first came under my observation. 

Under the use of the primary galvanic current to his 
brain, spinal cord, and affected muscles, and the internal 
use of chloride of barium, he is certainly improving, but I 
have little hope of any permanent result being obtained. 
His epileptic paroxysms are kept down with bromide of 
potassium. 

The second case occurred in the practice of Dr. J. C. 
Hubbard, of Ashtabula, Ohio, who forwarded to me the 
following excellent report, dated January 11, 1870, and two 
photographs — one full length on a small scale, and another, 
from which the woodcut, Fig. 30, has been engraved : 

" H. $., aged thirty-nine years, a farmer by occupation, 
married. His father and paternal grandfather were free 
drinkers of ardent spirits. His only brother died of phthisis 
pulmonalis, and I think he inherits a tubercular tendency 
from his mother. The patient is short, muscular, is well 
made, and has always had good health till about eight years 
ago, when he had several attacks of headache, followed by 
vertigo and loss of power to maintain the upright posture, 
or to sit in a chair. After falling, he lost consciousness for 
a few moments. He had three of these attacks in two 
months. 

" Three years after the last one, being five years and a 
half ago, while at work on a hot day in the open air, he 
lost consciousness and fell to the ground. This attack was 
more severe than the preceding ones, and he was confined 
to his bed three days. The headache was very severe, and 
continued a week after he left his bed. Aphasia, and the 
incoordination now affecting his right forearm and right leg, 
were the sequence of this stroke. His powers of speech 
were gradually reestablished in the course of six weeks, but 



ATHETOSIS. 659 

the impediment to normal voluntary muscular motion has 
remained to this day. 

" In June last [1869] he applied to me for relief from 
cephalalgia, pain in the right side of the chest, cough, and 
dyspnoea. He complained also of vertigo and of flashes of 
light before his eyes. His memory and judgment were 
slightly impaired, and he was gloomy and irritable. 

" His utterance of most words was perfect, but he stam- 
mered over at least one word in each sentence.' It required 
a good deal of effort for him to connect his ideas and his 
sentences. He stumbled at monosyllabic words, such as 
and, then, to, at, and other conjunctions, but in a moment, 
after considerable effort, he could speak these words and 
conjoin his sentences correctly. 

" On examining his right foot, I found that he had lost 
the normal antagonizing force between the flexors and 
extensors of the toes. The toes were ordinarily in a state 
of flexion, so as to present their ends to the floor. He could 
restore the balance in muscular action by a strong effort of 
the will, pressing at the same time the sole hard upon the 
ground, and drawing the foot backward a little. Soon, 
however, the extensors would be wearied by their extra 
work, and the toes would resume their abnormal position. 
The foot is slightly inverted at every step, and it is not ex- 
actly guided by the will. His gait is awkward — the foot 
being set down with a kind of pawing motion, as in talipes 
varus. 

"A similar incoordination is observable in the right 
hand and fingers. He cannot flex his fingers without the 
aid of the opposite hand, but when it is closed the grasp is 
as strong as ever. By an intense action of the will he can 
keep his fist closed for a few moments, till the apparently 
tired flexors give way. The little and ring fingers are but 
partially extended, and are strongly abducted. The ab- 
ductor minimi digiti, and the flexor brevis minimi digiti, 
are hypertrophied, firm, hard, and in a state of contraction 



QQO CEREBROSPINAL DISEASES. 

most of the time, and the affected hand measures three- 
fourths of an inch more around the palm than its fellow. 
Tactile sensibility is as perfect in the affected limbs as in 
the others. His muscular powers are good, and he thinks 
he can walk twenty-five miles without injurious fatigue. 
The temperature of the affected limbs is slightly lower than 
that of the opposite ones. Has slight headache frequent- 
ly, generally at evening ; sleep relieves it. He sleeps well 
when undisturbed by pains in his limbs. Tongue clean and 
tremulous. Has slow, moving pains, from the hand and 
foot up to the body. They often last half a day, and are 
worse at night. Has no. pain, tenderness, or feeling of 
weakness, in any part of the spine. 

" He had no systematic treatment till last June. The 
chest-symptoms referred to were owing to subacute bron- 
chitis. A seton was inserted between the shoulders, and 
iodide of potassium was administered for ten days. His 
lungs being then better, phosphoric acid, cerium, cannabis 
Indica, sulphate of quinine, and sulphate of iron, were given 
till the 1st of December following. He then felt so much 
better that he discontinued the medicines. The seton con- 
tinued to discharge till the date of this communication 
[January 11, 1870], and he presents at this time a very 
marked improvement. His headache is not severe, he has 
less pain in his limbs, and he speaks without hesitation. 
By a strong effort of the will he can close his hand without 
assistance. He came five miles on foot, in a driving snow- 
storm, to see me to-day." 

The accompanying woodcut (Fig. 30) is from one of Dr. 
Hubbard's photographs. The resemblance to the condition 
shown in Fig. 29 is very striking, and the histories of the 
two cases are so nearly identical, in regard to all essential 
points, as to leave no doubt that they describe instances of 
the same disease. Dr. Hubbard's case was probably, when 
he wrote the history, in a more advanced state than is mine 
at the present time. The distortion of the hand is certainly 



ATHETOSIS. 



661 



greater. In the other photograph, which is indistinct, the 
toes are seen fullv flexed. 



Fig. 30. 




The symptoms of athetosis are clearly indicated in the 
foregoing histories. Both cases came on with epileptic 
paroxysms— a feature accompanying other organic diseases 
of the brain and spinal cord. In both there are similar 
head-symptoms, tremulousness of the tongue, numbness on 
the affected side, pains in the spasmodically-affected mus- 
cles, and especially complex movements of the fingers and 
toes, with a tendency to distortion. In neither case is there 
any paralysis. Relative to the character of the lesion pro- 
ducing these symptoms, and its exact seat, I am not yet 
prepared to speak with any degree of certainty. The phe- 
nomena indicate the implication of intra-cranial ganglia, 
and the upper part of the spinal cord. The analogies of 
the affection are with chorea and cerebro-spinal sclerosis, 
but it is clearly neither of these diseases. One probable 
seat of the morbid process is the corpus striatum. 

I should not have incorporated these cases and remarks 
in the present treatise, but with the hope of calling out the 



662 CEREBROSPINAL DISEASES. 

experience of others on the subject, by directing attention 
to an affection which has probably heretofore been over- 
looked or confounded with some other. 1 

1 Since the foregoing chapter was written, my friend and colleague, Prof. 
Fordyce Barker, to whom I showed the cuts and described the cases, has in- 
formed me that several years ago he had an exactly similar case in his practice. 



SECTION IY. 
DISEASES OF NEBYE-CELLS. 



Under this section I propose to consider certain diseases 
which are dne to degeneration and atrophy of the cells in 
intimate relation with nerve-roots, and which immediately 
preside over the functions of the nerves arising from them. 

CHAPTER I. 

ATEOPHT AND DISAPPEARANCE OF TROPHIC NERVE-CELLS 
{PROGRESSIVE MUSCULAR ATROPHY). 

Although cases of progressive muscular atrophy were 
noticed by the older writers, the first systematic account of 
the disease was given by Duchenne, 1 in 1849. In 1850 M. 
Aran a published his memoir, in which he gives the histo- 
ries of eleven cases ; and three years subsequently Cruveil- 
hier 8 read a paper on the same subject before the Academie 
de Medecine. About the same time other memoirs were 
published on the subject. 

1 Atropine musculaire avec transformation graisseuse. Memoires de 1' Aca- 
demie des Sciences, 1849. 

2 Kecherches sur une Maladie non encore decrite du Systeme musculaire. 
Arch. Gen. de Med., 1850. 

3 Sur la Paralysie musculaire progressive atrophique. Arch. Gen. de Med., 
1853. 



664: DISEASES OF NERYE-CELLS. 

But, although Cruveilhier was not the first to write upon 
the affection in question, he was the first to describe it, and 
Duchenne and Aran were aware that he had done so in his 
lectures for several years. The disease is therefore some- 
times called Cruveilhier's atrophy. 

Symptoms. — The first symptom observed in the majority 
of cases is loss of strength and dexterity in certain muscles 
of the body. If these are in the lower extremities, the pa- 
tient finds that he tires in walking sooner than he used to 
do. If in the upper extremities, he experiences weakness 
in the shoulder, arm, or hand, according to the muscles 
affected. 

Soon afterward pains simulating those of neuralgia are 
felt in the paretic muscles, and in the majority of cases — 
according to my experience in all — fibrillary contractions are 
perceived. Thus, of twenty-nine cases of progressive mus- 
cular atrophy which have been under my charge during the 
past six years, these contractions formed a prominent feature 
in every one. They consist of slight twitchings of separate 
bundles of muscular fibres, and give the sensation of some- 
thing alive being under the skin. They can often be seen, 
especially when superficial fibres are involved, and they are 
generally the avant courriers indicating the extension of the 
disorder. 

The loss of strength attracts the attention of the patient 
to his limbs, and then he finds that the weakness is accom- 
panied by atrophy. If, as is usually the case, the disease 
begins in one of the upper extremities, the thenar and hypo- 
thenar eminences very commonly give the first evidence of 
atrophy. The ball of the thumb disappears, and the muscles 
filling the space between the first and second metacarpal 
bones — the adductor pollicis and the first interosseous — like- 
wise shrink away. The whole outline of the metacarpal bone 
of the thumb can thus very soon easily be made out. 

The ball of the thumb is often the starting-point of the 
disease, and, when this is not the case, it generally becomes 



PROGRESSIVE MUSCULAR ATROPHY. 665 

involved at some time or other in the course of the affection. 
Of the twenty-nine cases occurring in my experience, the 
disease appeared first in the ball of the thumb in eight, and 
eventually attacked this part in thirteen others. The upper 
extremities were the original seat of the disease in seventeen 
cases, the trunk in four, and the lower extremities in eight. 
Whether the affection begins in an upper or lower extremity, 
the tendency is for the opposite member to be next involved. 

The physiognomy of progress in muscular atrophy is very 
striking, particularly when the face or the hand is its seat. 
No very well marked case of the former has come under 
my observation, but it can readily be understood that the 
change effected by the disappearance of the facial muscles 
must be very evident. In the hand, the atrophy of the 
muscles which give this member its plumpness, and enable 
it to perform the complex movements of which the fingers 
are capable, causes appearances which are easily recogniza- 
ble. By the disappearance of the thenar and hypothenar 
eminences, the skin over them hangs in loose folds, the 
thumb falls by its own weight, and cannot be brought into 
apposition with the index-finger — the palm of the hand is 
hollowed out, and the metacarpal bones can be distinctly 
seen and felt. 

In the forearm, the situation of the disease can be readily 
ascertained by the flattening produced by the disappear- 
ance of the affected muscles, and in the arm and shoulder 
the effects of the disease are still more evident. In two 
cases, one of them sent to me by my friend Prof. Yan Buren, 
the disease had begun in the right deltoid, and had not ex- 
tended beyond this muscle when the patients came under 
my charge. In both, the shoulder was flattened, and the 
head of the humerus and the acromion process could be dis- 
tinctly seen. In another case it was limited to the trapezius 
and scapular muscles of both sides. 

In the lower extremity, the changes in the foot are not 
so remarkable as the corresponding ones in the hand, but the 



666 DISEASES OF NERVE-CELLS. 

effects produced by the atrophy of the peroneal muscles, the 
tibialis anticus, and those forming the calf of the leg, are very 
striking. In the one case, the foot drops, and the patient 
is obliged to bend the knee to a greater extent than usual 
in order to make the toes clear the ground ; in the other, 
the heel cannot be raised, and the ankle gives way with the 
weight of the body. When the muscles on the anterior face 
of the leg are in process of destruction, the forms of the tibia 
and fibula can be distinguished, and the space between the 
two bones is unfilled. The disappearance of the calf makes 
the posterior aspect of the leg flat. 

In the thighs the atrophy is also readily perceived, and 
modifies very materially the gait of the patient. "When the 
extensors on the anterior face of the thigh are involved, the 
leg cannot be thrown forward ; when the flexors are the seat, 
the leg cannot be raised, and the whole member has to be 
lifted up by the action of the flexors of the thigh on the 
pelvis. 

In the accompanying woodcut (Fig. 31), taken from a 
photograph, there is an excellent representation of the 
lower extremities of a patient affected with progressive mus- 
cular atrophy. He formed the subject of my clinical 
lecture on this disease at the Bellevue Hospital Medical 
College, February 18, 1871, having the same day been ad- 
mitted to the New York State Hospital for Diseases of the 
Nervous System. The affection began with electric pains 
in the legs, weakness, and head-symptoms, consisting of con- 
fusion of ideas, vertigo, dimness of vision, headache, etc. 
There was also numbness in both the lower and upper ex- 
tremities. He partially recovered, but in May, 1867, there 
was a return of the head-symptoms, the electric pains, and 
numbness, to which were superadded cramps, fibrillary con- 
tractions in both hands and legs, with tingling and twitch- 
ing. In the course of three weeks he was obliged to use 
crutches. From this time, he noticed the atrophy of the 
muscles of both legs, and it has gradually extended till it 



PROGRESSIVE MUSCULAR ATROPHY. 



667 



has involved the muscles of the lower third of both thighs. 1 
In the legs, the extensors are almost entirely destroyed, as 
are also the gastrocnemii and solei. The figure, owing to 
the position of the patient when the photograph was taken, 
does not show very well the effects of the disease in the legs, 
but the atrophy in the thighs is distinctly indicated. 



Fig. 31. 




Besides the paralysis, which it must be clearly under- 
stood results from the atrophy, and is directly proportional 
to its extent, there may be contractions. These, when pres- 
ent, are due to the fact that the atrophy has not attacked 
all the muscles of an extremity simultaneously, or to a like 

1 From notes prepared by Dr. Cross, Resident Physician of the hospital. 



668 DISEASES OF NERVE-CELLS. 

degree, and consequently, the normal antagonism being de- 
stroyed, distortions take place. When these occur in the 
hand, they produce the main en griff e of Duchenne. Of 
the twenty-nine cases occurring in my experience, seven 
only had any distortions. In infantile paralysis, which is 
similar in several respects to progressive muscular atrophy, 
contractions and distortions are much more common. 

The reflex movements are generally diminished, except 
in the early stages, while the fibrillary contractions are pres- 
ent, and the electric contractility diminishes pari passu with 
the muscular tissue. The temperature of the affected parts 
is always lowered several degrees, and the capillary circula- 
tion is languid. 

The pupils are sometimes contracted from the implication 
of nerve-cells in the cilio-spinal region of the cord. This was 
the case in one or both eyes in four of my cases. 

The course of the affection is slow, but in the great ma- 
jority of cases it advances to a fatal termination. Death 
takes place from the muscles of respiration becoming in- 
volved, from exhaustion, or from some intercurrent affection. 
Several of my cases have lasted over ten years. 

In a recently-published memoir, MM. Duchenne and 
Joffroy ' have shown that glosso-labio-laryngeal paralysis is 
sometimes complicated with progressive muscular atrophy, 
and that this latter affection, implicating the muscles of the 
tongue, the lips, and the veil of the palate, has hitherto been 
confounded with the first-named disease. It differs from it, 
however, in the essential fact, which is applicable to the 
disorder appearing in other parts of the body, that the loss of 
power is not the initial symptom, but results directly from 
the diminution in the size of the muscles. 

Causes. — Progressive muscular atrophy is not a disease of 
old age. Only one of my cases was in a person over fifty ; 
two were between forty and fifty, and twenty-six were under 

1 De l'Atrophie aigue et chronique des Cellules nerveuses de la Moelle et du 
Bulbe rachidien. Arch, de Phys., No. 4, 1870, p. 499. 



PROGRESSIVE MUSCULAR ATROPHY. 669 

forty. Of these latter, two were between fifteen and twenty, 
and two between eight and ten. The period of life at which 
it appears to be most common is that extending from twenty- 
five to thirty-five. 

Sex is a strong predisposing cause. All of my cases 
were in males. Roberts 1 states that, of ninety-nine cases, 
eighty-four were males, and only fifteen females. Other 
authors have noted the great proclivity of males. The dif- 
ference appears to be due to the greater severity of muscular 
exertion required in many of the occupations of men. 

Hereditary influence is a well-recognized predisposing 
cause. Two of my cases sent to me by Dr. Lincoln, of Wash- 
ington City, were brothers, and nine others had relatives 
affected with the disease. 

The exciting cause is often impossible of detection. This 
was the case in eighteen of the instances that have come 
under my observation. Of the remaining eleven, injuries 
of the spine were the cause in two ; exposure to cold and 
dampness in three, and excessive muscular exertion in six. 
Of these latter cases, one occurred in the person of a ballet- 
dancer, the disease making its appearance first in both gas- 
trocnemii muscles simultaneously ; one in a gentleman who f 
had overtasked the muscles of the upper extremities by severe 
and long-continued exertion in rowing, the muscles about 
the shoulders being affected ; in one, the muscles of the 
right hand were first attacked, as the result of excessive use 
of the pen in writing ; in one, it was induced by the occu- 
pation, that of a bricklayer, requiring the patient to bear 
the weight of his body, during his work, mainly on one leg — 
the one attacked ; in one, it was apparently induced by 
running a long distance ; and in one, it attacked the muscles 
of the hand and forearm, beginning in the ball of the thumb 
in a man whose occupation — faro-dealer — required him to 
use his thumb and fore-finger in a peculiar way for many 
hours at a time. 

1 An Essay on Wasting Palsy. London, 1858, p. 135. 



670 DISEASES OF NERVE-CELLS. 

Diagnosis. — The sharp, shooting, electric pains may, in the 
beginning, cause progressive muscular atrophy to be mis- 
taken for posterior spinal sclerosis, but the subsequent symp- 
toms are so very obvious, that the error cannot be of long 
duration, and are of such a character as to render the recog- 
nition of the affection a matter of no difficulty. 

Prognosis. — From what has been said, it will readily be 
apprehended that progressive muscular atrophy is a very 
serious disease ; indeed, it is one of the most progressive of 
all the affections to which the term has been applied. 

In only two cases have I succeeded in arresting the course 
of the disease, and in restoring the atrophied muscles. One 
of these was that of a highly-intelligent gentleman, formerly 
an officer of the navy, but now a resident of this city, whose 
case has already been referred to as having been induced by 
rowing ; the other, was that of the patient sent to me by 
Prof. Yan Buren, also previously mentioned, in whom the 
affection was induced by cold, and which began in the right 
deltoid muscle. Both of these patients were entirely cured, 
regaining full muscular power. 

In three other cases, which I saw before the disease had 
advanced to a great extent, its progress was arrested, but 
there has as yet been no restoration of the wasted muscles ; 
in neither of these was there any probable cause of the 
affection. 

The existence of an hereditary tendency renders the 
prognosis much more grave ; and the fact of the disease 
having lasted a long time is also of unfavorable import. 

Morbid Anatomy. — Investigations in regard to the morbid 
anatomy of progressive muscular atrophy relate to the con- 
dition of the muscles, of the nerves supplying them, and of 
the centres from which the nerves are derived. 

The atrophy of the muscles is due to the degeneration 
and ultimate disappearance of the fibril lse. To the naked 
eye they appear pale and attenuated. By microscopical 
examination, it is seen that the transverse striae of the fibril- 



PROGRESSIVE MUSCULAR ATROPHY. 671 

lae are in course of disappearance, and as the disease advances 
they are perceived to fade away altogether. Eventually, the 
longitudinal striae also disappear. At the same time, the 
muscular fibrillse break up into granules, and then undergo 
regressive metamorphosis into fat. It is not uncommon to 
see a bundle of fibrillge, in one part of which the transverse 
striae only have vanished ; in another, the longitudinal ; in 
another, the process of disintegration complete ; and in 
another, oil-globules occupying their place. Fat-corpuscles 
are frequently found deposited between the bundles of fibril- 
I33. After a time the fat disappears, and nothing is left of 
the muscle but a cord of connective tissue made up of the 
myolemma. 

By means of the little trocar described in the introduc- 
tion, I have frequently removed small pieces of atrophied 
muscles during life, and submitted them to microscopical 
examination. 

The anterior roots of the spinal nerves ultimately dis- 
tributed to the affected muscles are generally found atro- 
phied, from the disappearance of a certain number of nerve- 
tubes. This feature was first observed by Cruveilhier. 

The spinal cord has been examined in cases of progres- 
sive muscular atrophy by Bergmann, Meryon, Gull, Luys, 
Lockhart Clarke, and others, with very different results ; 
some of these observers finding no change whatever, and 
others detecting notable variations from the normal struct- 
ure. In three cases examined by Clarke, 1 disorganization 
of the spinal cord, especially of the gray matter, was found, 
with, in one case, deposit of amyloid corpuscles. 

More recently Hayem, 2 and Charcot and Joffroy, 3 have 

1 Beale's Archives of Medicine, vol. iii., 1861 ; also, same, vol. iv. ; also, 
British and Foreign Medico-Chirurgical Review, vol. xxx., 1862. 

2 Note sur un cas d' Atropine musculaire progressive, avec Lesions dela Mo- 
elle. Archives de Physiologie, No. 2, 1869, p. 221, and No. 3, 1861, p. 391. 

3 Deux Cas d' Atropine musculaire progressive, avec Lesions de la Substance 
grise et du Faisceaux antero-lateraux de la Moelle epiniere. Arch, de Phys., 
Nos. 3 and 5, 1869. 



672 DISEASES OF NERVE-CELLS. 

studied the morbid anatomy of progressive muscular atrophy 
with great care. In Hayem's case, the disease affected the 
muscles of the upper extremities to such an extent as 
to render them powerless from the shoulders down. The 
patient died from paralysis of the diaphragm and of pneu- 
monia. 

On post-mortem examination, the spinal cord appeared 
healthy to the naked eye. The anterior roots of the cervical 
nerves were, however, notably atrophied. The most atten- 
uated were those of the second, third, fourth, and fifth pairs. 
The sympathetic was healthy. On microscopic examination 
of the cord, the most marked characteristic was atrophy and 
disappearance of the nerve-cells. In some portions there 
were none to be seen, but there were large numbers of free 
nuclei, and of cells containing many nuclei. The atrophy 
of the nerve-cells, and of the anterior cornua of gray sub- 
stance, was greatest at the level of the second and third cer- 
vical nerves, and extended as low as the fifth cervical. This 
region was that from which the nerves supplying the atro- 
phied muscles were derived. In the dorsal and lumbar 
regions there was no atrophy of nerve-cells or of nerve 
roots. 

A consideration of this case shows, as Hayem remarks, 
that it is one which, during life, exhibited the usual symp- 
toms of progressive muscular atrophy, and that, at the post- 
mortem examination, lesions were found in the muscles in 
the anterior roots of the nerve, and, above all, in the spinal 
cord. The alterations from the healthy structure of the 
cord consisted of 

1. Abnormal vascularization with dilatation, and sclerosis 
of the arterioles, and of the larger capillaries. 

2. A more or less abundant exudation surrounding the 
blood-vessels. 

3. Multiplication of the elements of the interstitial tissue 
(the neuroglia), and, finally, atrophy, and disappearance of a 
very great number of the nerve-cells. 



PROGRESSIVE MUSCULAR ATROPHY. 673 

These facts point to the existence of chronic inflamma- 
tion of the gray substance of the cord. 

The two cases of MM. Charcot and Joffroy have also been 
very carefully and thoroughly studied. 

The chief features of the first case were, progressive mus- 
cular atrophy, especially marked in the superior extremities ; 
atrophy of the muscles of the tongue and of the orbicularis 
oris, and paralysis with rigidity of the inferior extremities. 
The patient was a woman, and, becoming suddenly very 
weak, died asphyxiated. 

At the autopsy, the anterior roots, especially those of the 
cervical region, were found greatly atrophied and discolored. 
The cord appeared healthy to the naked eye, except that at 
the dorso-lumbar enlargement it was softened. On micro- 
scopical examination, however, the nerve-tubes of the anterior 
columns were discovered to be atrophied, a great number 
being only represented by the axis cylinder while the con- 
nective tissue was very much increased. The posterior col- 
umns were not involved in the least. 

In examining the gray substance of the cervical region, 
the authors were struck with the extreme degree of atrophy 
which the cells of the anterior cornua had undergone; 
a large proportion of them had entirely disappeared, 
leaving no trace behind them. The posterior cornua ap- 
peared to exhibit all the qualities of the normal condi- 
tion. 

The alterations in the other regions of the cord were not 
directly connected with the progressive muscular atrophy, 
except as regards the medulla oblongata where the cells of 
the nuclei of origin of the hypoglossal were found to be 
atrophied, and even completely destroyed. In the second 
case, similar structural changes were found. 

The essential points in the morbid anatomy of progres- 
sive muscular atrophy are no longer a matter of doubt. 
The bearing of these points on the real nature of the disease 
is next to be investigated. 
43 



674 DISEASES OF NERYE-CELLS. 

Pathology. — At the outset of the inquiry relative to the 
pathology of progressive muscular atrophy, the question 
arises, Is the affection a disease primarily of the muscles or 
of the nervous system ? From the fact that the wasting of 
a muscle so frequently resulted from its excessive use, it 
was, and still is, supposed by some pathologists that the 
lesion is essentially one of the muscles, and that the nerves 
and spinal cord are secondarily involved. But the conclu- 
sion does not logically follow the premise, and observation 
shows, very conclusively that excessive use of a muscle ex- 
hausts, not the muscle primarily, but that p'art of the ner- 
vous centre from which the nerves come which supply that 
muscle. The consequence of this exhaustion is atrophy 
and disappearance of certain cells in intimate relation with 
the roots of the nerves supplying the atrophied muscles. 
By this theory is to be explained the occurrence of progres- 
sive muscular atrophy in the legs of the ballet-dancer, and 
the thumb of the faro-dealer, previously mentioned. 

The destructive metamorphosis of the nerve-centre pro- 
ceeds at a greater rate than its nutrition, owing to the ex- 
treme demand made upon it by the muscles put in excessive 
action, and hence their atrophy and disappearance. 

A central disease being thus set up, it extends by con- 
tiguity and involves those nerve-cells which are nearest. 
These are the cells which supply the corresponding nerves 
of the opposite side, and therefore it is that the disease, like 
several others, tends to advance symmetrically, affecting 
homonymous muscles. 

Of course it frequently happens that progressive mus- 
cular atrophy may originate from disease of the nerve-cells 
without the muscle having been put to inordinate use. In 
such cases the process is one of excessively chronic inflam- 
mation. 

One other very important question remains to be con- 
sidered, and that relates to the physiological character of 
the cells which have degenerated and have disappeared. 



PROGRESSIVE MUSCULAR ATROPHY. 675 

The spinal cord is admitted to be connected with two 
distinct faculties — motion and sensation. It is probable, 
therefore, that there are at least two kinds of nerve-cells in 
the gray substance of the cord, which, though alike in ana- 
tomical characteristics, differ essentially in their functions. 
One set is motor and one sensory. In those cases of spinal 
paralysis involving motion, and in which there is atrophy 
of nerve-cells, the motor cells are diseased ; in those in 
which sensation is affected, and in which atrophy of nerve- 
cells is discovered, the sensory cells are the ones . impli- 
cated. 

Xow, progressive muscular atrophy, pure and uncom- 
plicated, is unattended by derangements of sensation, and 
unaccompanied by paralysis, except such loss of power as is 
directly due to the diminution of the volume of the affected 
muscles. The presumption is, therefore, that neither the 
motor nor the sensory cells have disappeared or become 
atrophied, and yet, on post-mortem examination, we find 
that nerve-cells of some kind have been diseased. The pre- 
sumption is, and it is reasonable, that these are cells which 
are specially connected with the nutrition of muscles — tro- 
phic cells — and that progressive muscular atrophy is a symp- 
tom indicating the existence of disease of the trophic cells. 
The verv existence of these cells is a matter of inference, but 
in my opinion the argument in favor of the affirmative is 
very much strengthened by the facts furnished by the morbid 
anatomy of progressive muscular atrophy. Dr. Handfield 
Jones 1 has recently written forcibly against the existence 
of any special trophic nerves, and, by extension of reasoning, 
trophic nerve-cells. But he was unaware of the more re- 
cent researches of Duchenne and Joffroy, 3 upon which, in 
accordance with these observers, I have based my views of 

1 Are there Special Trophic Nerves ? St. George's Hospital Reports, voL 
iii., 1868, p. 89. 

2 De r Atropine aigue et chronique des Cellules nerveuses, etc. Archives de 
Physiologie, No. 4, 1870, p. 499. 



676 DISEASES OF NEKVE-CELLS. 

the pathology of progressive muscular atrophy, and to which 
I have already alluded. 

Treatment. — The treatment of progressive muscular atro- 
phy is nothing without the use of the primary galvanic cur- 
rent. This should be applied every alternate day to the 
spinal cord, and to the sympathetic nerve. In the first in- 
stance the current should be employed in the manner recom- 
mended under the head of spinal anaemia ; in the latter the 
positive pole should be applied to the cilio-spinal centre, 
and the negative to the sympathetic nerve in the neck. 
The current should be strong enough to give a decided sen- 
sation — that from fifteen to twenty Smee's cells will usually 
be sufficient — and it should be applied for about ten min- 
utes to the cord, and five to the sympathetic every alternate 
day. 

At the same time both the primary and induced currents 
are efficacious in improving the nutrition of the atrophied 
muscles, by applications made either directly, or to the nerves 
which supply them. 

For internal treatment, the means recommended for 
posterior spinal sclerosis are the best. Iodide of potassium 
should of course be given when there is suspicion of syphi- 
litic taint. 

Hydrotherapeutics may be of service, and a few cases 
have been reported of benefit therefrom. 

The treatment recommended should be continued for 
several weeks before "any decided opinion can be given rela- 
tive to its efficacy, and for many months before a cure can 
be expected. 



CHAPTER II. 

ATROPHY AND DISAPPEARANCE OF MOTOR NERVE-CELLS. 

Although it is probable that there are several diseases 
which consist of atrophy and disappearance of motor nerve- 
cells, only one has been so far studied sufficiently as to war- 
rant our associating it with the lesion in question, and that 
is — 

GLOSSO-LABIO-LARYNGEAL PARALYSIS. 

The first explicit account of this very remarkable disease 
is that of Duchenne, 1 who, in consideration of the tendency 
of the morbid process to advance unchecked, and of the 
parts affected, designated it "progressive muscular paral- 
ysis of the tongue, the veil of the palate, and the lips." 
The consequences of this condition, as pointed out by Du- 
chenne, are difficulties of articulation and of deglutition, 
and at a late period of the disease frequent attacks of stran- 
gulation, during one of which the patient may die ; or death 
may result either from inanition or syncope. 

But, although Duchenne was the first to give a system- 
atic description of the affection, it was observed by Trous- 
seau in 18ttl, just twenty years .before the publication of 
Duchenne's account, who recognized it as an affection he 
had not previously seen, and who wrote a memorandum of 
the existing phenomena. 2 Trousseau named the disease 
glosso-laryngeal paralysis, in his lecture on the subject, and 

1 De l'Electrisation localisee, etc., deuxieme edition, Paris, 1861, p. 621. 

2 Lectures on Clinical Medicine, Bazire's translation, p. 117. 



678 DISEASES OF NERVE-CELLS. 

this was afterward amplified by Duchenne into glosso-labio- 
laryngeal paralysis. Many eases have been subsequently 
reported, and descriptions of the affection given, but no 
one has added any thing to the graphic symptomatology of 
Duchenne. 

Eight cases of the disease have come under my observa- 
tion during the past six years. I am enabled, therefore, to 
describe it from my own observation of its phenomena. 

Symptoms. — It rarely happens that patients seek medical 
advice for the initial symptoms of the disease under notice. 
"We are therefore, in general, obliged to rely on their ac- 
counts of the order and progress of the symptoms. In one 
instance only — and this patient is still under treatment — 
have I had the opportunity of observing a case from a very 
early point in the course of the disease. 

The first evidence of disease, which in the majority of 
instances attracts the attention of the patient, is a slight 
difficulty of articulation, due to a want of rapidity and ex- 
actness in the movements of the tongue. This circumstance 
occurred in seven of my cases. In the other the symptom 
first noticed was a tendency in the lips to remain separate, 
and the consequent necessity of using some degree of mental 
action to keep them closed. In a short time the restraint in 
the motions of the tongue becomes more distinctly marked, 
and it is especially characterized by an inability to raise the 
extremity to the roof of the mouth, or to press it against the 
upper teeth. The words, therefore, which he experiences 
most difficulty in pronouncing distinctly are those which 
begin with lingual or dental consonants. The gutturals he 
can articulate without trouble ; and the labials, except when 
the affection begins in the lips, do not yet give him incon- 
venience. 

The next symptom to make its appearance is difficulty 
of swallowing. The food is not promptly grasped by the 
constrictor muscles of the pharnyx, and the tongue does not 
press it strongly against them. At times it enters the 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 679 

pharynx, and, not being carried onward by the muscles of 
deglutition, may slip into the larynx and occasion suffoca- 
tion. Liquids are especially difficult to swallow, and are 
often ejected through the nostrils. 

As the result of this paralysis of the muscles of deglu- 
tition, the saliva, instead of being swallowed as fast as 
secreted, accumulates in the mouth. Here it becomes 
stringy from its mixture with the buccal mucus, and when 
the patient opens his lips it runs out in streams. After a 
time the orbicularis oris becomes so far paralyzed that the 
lips cannot be kept closed without continual exertion, and 
then the viscid saliva is constantly flowing out of the mouth. 
In one of the cases mentioned as being under my charge, 
there was from the first some flow of saliva from the mouth, 
not apparently from any difficulty of swallowing, but from 
the existing paralysis of the orbicularis oris allowing the 
mouth to. be almost constantly open. The other muscles 
supplied by the facial nerve in the lower part of the face, 
singularly enough, do not become involved. The food, it is 
true, accumulates between the gums and the cheeks, and 
has to be removed with the finger, but this is not due to 
any paralysis of the buccinator muscles, but to the want of 
power in the tongue to move the alimentary bolus around 
the cavity of the mouth. 

When the disease is thus fully developed by the paralysis 
of the tongue, the veil of the palate, and the lips, the pa- 
tient presents a pitiable spectacle. He is unable to talk ; 
his teeth are exposed, from the impossibility of closing his 
mouth ; the saliva either runs in streams over the lower lip, 
or he goes about with a handkerchief in his hand which he 
uses to absorb the perpetual flow ; every attempt at deglu- 
tition causes him the utmost distress, and puts him in 
danger of his life from strangulation. When he opens his 
mouth the glutinous saliva is seen hanging in viscid strings 
from the roof, and his tongue, which he cannot move, lies 
torpid like an inert mass of muscles as it is. 



680 



DISEASES OF NERVE-CELLS. 



The facial expression is well seen in the accompanying 
woodcut (Fig. 32), made from a very accurate sketch of one 



Fig. 




of my patients suffering from the disease in question, and 
who entered my consulting-room with his handkerchief to 
his mouth to absorb the streams of saliva which were flow- 
ing. 

The condition of the patient becomes still more painful 
from the implication of the respiratory muscles. The walls 
of the chest become paralyzed, and he is unable not only to 
breathe deeply, but to cough so as to keep the bronchial 
tubes clear of accumulations of mucus. So feeble is the 
respiratory power, that with all the effort he can make he 
cannot blow out a candle. 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 681 

And, besides the impossibility of articulation, the lar- 
ynx becomes paralyzed at a later period of the disease, 
and phonation becomes impossible. The patient is then 
doomed to perpetual silence, even the power of whispering 
being lost. 

A remarkable fact is characteristic of many cases of 
glosso-labio-laryngeal paralysis, and that is the tendency of 
the morbid action to extend so as to implicate other nerve- 
cells lower down in the spinal cord. But the cells thus 
affected are not motor, but trophic, and as a consequence 
the resulting condition is not paralysis but muscular atro- 
phy. In none of my cases was there muscular atrophy in 
any part of the body, but in one, to be presently referred to 
more at length, there was incipient paralysis of the right 
arm. The case was, therefore, similar to the one reported 
by MM. Duchenne and Joffroy in their memoir already 
cited. 

Gradually, as the disease advances, the physical powers 
of the patient yield. He becomes unable to walk, not from 
paralysis, but from general debility, due to insufficient nu- 
trition and imperfect respiration. His appetite remains 
good, but he is afraid to take any more food than is barely 
sufficient to sustain life, for experience nas taught him that 
suffering and danger are attendant on every attempt at 
deglutition. At last he ceases to make the effort, and is fed 
with liquid food through a stomach-tube. The saliva during 
sleep runs down his throat, and fits of suffocation are the 
result. Too weak to walk, he remains in bed, his head turned 
to one side so as to allow free egress for the saliva, and he 
dies either from asphyxia, from the cessation of the action of 
the heart through the continued extension of the lesion to 
the cells supplying the pneumogastric nerve, or from some 
intercurrent affection. 

Generally the mind remains clear to the last, but in a 
very interesting instance of the disease sent to me by my 
friend Dr. Fleming, of Pittsburg, this was not the case, 



682 DISEASES OF NERVE-CELLS. 

manifest dementia making its appearance toward the close. 
The emotions are, however, almost invariably easily ex- 
cited. 

The first case of this disease coming under my observa- 
tion was one sent to me, over three years ago, by my friend 
Dr. Edward Bradley, of this city. The patient was a watch- 
maker, and very intelligent. Though unable to speak a 
word, I obtained a good deal of information from him rela- 
tive to his disease by asking him questions, the answers to 
which he wrote. The accompanying fac simile of one of 
his written communications to me (Fig. 33) will, I doubt 
not, prove of interest. It was made partially in answer to 
questions, and partially at his own suggestion. The date 
(March, 1847) was given in answer to my question when the 
disease appeared, and the year mentioned is a mistake for 
1867. As he states, there was a little trouble with his right 
arm. This was of the nature of paralysis, there being no 
muscular atrophy anywhere. The patient died about six 
months after I saw him, the disease lasting a little over a 
year. 

The last case — the eighth — is a patient in the New York 
State Hospital for Diseases of the Nervous System. In him 
the affection began in the orbicularis oris, and has gradually 
involved, though as yet slightly, the tongue and muscles of 
deglutition. The left side was first involved, and then, a 
few weeks afterward, the paralysis extended to the right. 
There is nystagmus of both eyes. The mind is perfectly 
clear. He formed the subject of a recent clinical lecture 
on glosso-labio-laryngeal paralysis, which I delivered dur- 
ing the session of 1870-'71, at the Bellevue Hospital Medi- 
cal College. The case is further remarkable as occur- 
ring in an exception ably young person, the patient being 
but thirty-two years of age. Duchenne x states that he has 
never observed it in persons under forty. I subjoin a rep- 

J De l'Etectrisation localisee, Paris, 1861, p. 648. 



684 



DISEASES OF NERVE-CELLS. 



reservation of this patient (Fig. 34), taken from a photo- 
graph. The paralysis of the orbicularis oris is evident 
although it is partly concealed by the mustache. At the 
time it was taken the patient could swallow, but was con- 
scious of a difficulty in beginning the act of deglutition. 



Fig. 34. 




Causes. — The etiology of glosso-labio-laryngeal paralysis 
is very obscure. Duchenne attributes one of his cases to 
mental anxiety ; two cases appeared to be due to syphilis 
and rheumatism. In no other instance could he assign a 
cause. 

Of my own cases, one was apparently due to business 
troubles resulting from petroleum speculations ; and in one, 
that of a gentleman from Kansas City, Missouri, who came 
here to consult Prof. Sayre and myself, excessive application 



GLOSSO-LABIO-LARNYGEAL PARALYSIS. 685 

to business appeared to be the cause. In one other case, 
that of a gentleman of this city, the disease was evidently 
associated with syphilis. In none of the others conld I 
assign any cause. All of my patients were between the 
ages of forty and sixty, except the one whose portrait has 
just been given. 

Diagnosis. — Attention to the account of the symptoms 
given will prevent any mistake in diagnosis, as there is no 
affection which resembles in its entirety the one under con- 
sideration. In the very early stage, however, it may be 
confounded with simple paralysis of the tongue ; or, if the 
disease begins in the lips, as in the case cited, with facial 
paralysis. In glossoplegia there are other symptoms of 
cerebral disorder, and in facial paralysis the difficulty is not 
confined to the lips. 

It may possibly, in some cases, not be distinguished from 
the general paralysis of the insane, which generally begins 
with paralysis of the tongue and weakness of the lips. The 
facts that this disease is manifested also by mental symptoms, 
and that the paralysis gradually involves the other muscles 
of the body, will suffice for making an exact diagnosis. In 
facial diplegia the expression of countenance is very much 
like that of a patient suffering from glosso-labio-laryngeal 
paralysis, but here the resemblance ends, and careful exami- 
nation shows even here many points of difference. It is 
only necessary to state that the tongue is not paralyzed, and 
that there is no difficulty of swallowing in double facial 
paralysis. 

In progressive muscular atrophy, attacking the tongue, 
the veil of the palate, and the lips, a mistake might also be 
made. But, as Duchenne remarks, progressive muscular 
atrophy rarely begins in that way, and, when it does, other 
muscles of the body, especially the thenar and hypothenar 
eminences, will soon become involved. Charcot ' has, how- 
ever, recently reported a case in which progressive muscular 

1 Archive de Phys., No. 2, 1870, p. 247. 



(386 DISEASES OF NERVE-CELLS. 

atrophy was clearly combined with glosso-labio-laryngeal 
paralysis, and in which, on post-mortem examination, though 
the volume of the tongue was not diminished, the muscular 
fibre had undergone degradation. In such a case, of course, 
a complete diagnosis could only be made after death. In- 
ordinary progressive muscular atrophy, the fact previously 
insisted upon, that the atrophy comes on before the paralysis, 
is applicable here. 

From diphtheritic paralysis, attacking the muscles of the 
pharynx, glosso-labio-laryngeal paralysis is readily distin- 
guished by inquiries relative to the history of the case, and 
by the fact that the tongue is not involved in the first- 
named disorder. 

Prognosis. — There is no instance on record of a cure. All 
my patients affected with the disease are dead but one, and 
with him the affection is slowly advancing. Ameliorations 
may certainly be produced, but probably no cure. The 
average duration of the disease is about two years. 

Morbid Anatomy. — Previous to the very recent researches 
which have given us a clear insight into the morbid anatomy 
of glosso-labio-laryngeal paralysis, the lesions, detected by 
several observers, were atrophy of the roots of the hypo- 
glossal, facial, spinal accessory, and pneumogastric nerves. 
But late investigations have shown that the lesions of the 
nerve-roots are secondary to others more central in their 
situation. 

It has already been shown, under the head of progressive 
muscular atrophy, that the morbid process in that disease 
consists of atrophy and disappearance of nerve-cells forming 
the nuclei of origin of certain nerves. Very minute exami- 
nations, made in the cases of persons dying of the disease 
under notice, show very clearly that it also consists of 
atrophy and disappearance of nerve-cells. 

Thus, in the case just cited from Charcot, the post-mortem 
examination revealed the fact of atrophy of the nerve-roots 
supplying the paralyzed muscles, and microscopical investi- 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 687 

gation showed that the nerve-cells in relation with the fila- 
ments of origin of the hypoglossal, the spinal accessory, the 
pneumogastric, and the facial were altered, and had many of 
them disappeared. In the case which Duchenne has made 
the basis of some original views on the subject of atrophy of 
nerve-cells, and which has already been cited several times, 
it was found that the cells constituting the nuclei of origin 
of the hypoglossal, the facial, the spinal accessory, and the 
pneumogastric, had become atrophied, and had disappeared 
to a remarkable extent. 

It may, therefore, be considered as satisfactorily deter- 
mined, that the essential lesion in glosso-labio-laryngeal 
paralysis is found in the medulla oblongata and upper part 
of the spinal cord, and that it consists of atrophy and dis- 
appearance of certain nerve-cells constituting the nuclei of 
origin of the hypoglossal, the facial, the spinal accessory, and 
the pneumogastric nerves. 

Pathology. — What is the nature of the nerve-cells which 
have been diseased ? In progressive muscular atrophy, we 
saw that there was ample reason for supposing them to be 
cells that especially presided over the function of nutrition — 
trophic cells ; for that disease is one in which the lesion, so 
far as the muscles are concerned, consists of deficient nutri- 
tion. Glosso-labio-laryngeal paralysis is not, however, a 
disease in which the muscles are defectively nourished, but 
one the essential feature of which is paralysis. It is reason- 
able, therefore, to suppose, with Duchenne, that the nerve- 
cells which have become diseased are motor cells. As re- 
gards the relation of the symptoms observed to the known 
distribution and functions of the nerves concerned, there is 
no difficulty. The affection of the hypoglossal causes the 
paralysis of the tongue, and the consequent impossibility of 
articulation, and of moving the food in the mouth. The im- 
plication of the facial accounts for the paralysis of the lips 
and the muscles of the veil of the palate, and the resultant 
impossibility of sounding certain letters, and of swallowing. 



688 DISEASES OF NERVE-CELLS. 

The extension to the spinal accessory explains the paraly- 
sis of the larynx, the loss of phonation, and the feebleness 
of respiration ; and death, when it takes place as it some- 
times does from the sudden stoppage of the heart's action, is 
due to the implication of the pneumogastric, to which cause 
other paralyses of the muscles of animal life are to be as- 
cribed. 

Treatment. — From what was said relative to the prog- 
nosis, it will have been perceived that there is not much 
to expect from treatment. I have, however, occasionally 
produced good results which have, for a time, at least, ren- 
dered the condition of the patient more tolerable. Thus, 
the first patient who came under my care was much relieved 
by faradization of the paralyzed muscles. He improved very 
much in his ability to swallow, and in power over his tongue 
and lips. These ameliorations were not permanent. In the 
case of the gentleman from Pittsburg, as well as in all the 
other cases but one, similar treatment, together with the use 
of the primary galvanic current and phosphorus, was with- 
out the least effect. In this latter case, which is now under 
treatment, some benefit has apparently resulted. The course 
of the disease is certainly less rapid than before treatment 
was begun, but it is nevertheless, in my opinion, slowly ad- 
vancing. 



CHAPTEE III. 

ATBOPEY AND DISAPPEARANCE OF MOTOR AND TROPEIG 
NERVE- CELLS. 

ORGANIC INFANTILE PAEALYSIS. 

Under the name of organic infantile paralysis, I have 
described at length 1 a form of paralysis occurring in young 
children, previously described by Eilliet and Barthez as the 
Paralysie essentielle de Ven/ance, and by Duchenne 2 as 
Paralysie atrophique graisseuse de Penfance. Previous 
to the writings of these authors, the affection in question 
was not distinctly recognized as a separate disease, but was 
confounded with a much less serious disorder, probably 
belonging to the class already considered under the head of 
anaemia of the anterior columns of the spinal cord. The 
tendency in the present affection to muscular atrophy, and 
the permanent character of the paralysis, are phenomena 
which sufficiently distinguish it from the temporary paralysis 
referred to. 

Symptoms. — Organic infantile paralysis is generally pre- 
ceded by febrile excitement and pain in the back. This pain 
marks the seat of the disease in the spinal cord to which the 
paralysis of the muscles is due. These symptoms last for a 
few days, or they may be so slight as in very young children 
not to attract attention. 

1 Journal of Psychological Medicine, No. 1, 1867, p. 49. Also, my trans- 
lation of Meyer's Electricity in its Relations to Practical Medicine. New York, 
1870, p. 228, note. 

2 Traite, clinique et pratique, des maladies de l'enfance. Paris, 1853, t. ii., 
p. 335. 

44 



690 DISEASES OF NERVE-CELLS. 

Sometimes the paralysis is readily observed from the 
first, both by the extent and intensity ; at others, it is not 
perceived till some one notices that the child does not use 
one hand or kick with one leg. The age of the patient of 
course exercises considerable influence on the question of as- 
certaining the existence of the paralysis at an early period. 

The temperature of the affected limbs is always much 
lower than that of the corresponding sound ones. The dif- 
ference is sometimes as much as eight or ten degrees, though 
generally it is not more than five. If, under appropriate 
treatment, amendment takes place, the first indication is 
shown by the return of the temperature toward the natural 
standard. It thus becomes important to have some means 
by which a very slight increase of heat may be noticed. A 
delicate thermometer graduated to tenths of a degree will 
generally suffice, but much more exact indications may be 
obtained by Becquerel's disks, which are placed in commu- 
nication with a galvanometer. These disks consist of a very 
thin plate of copper, about the size of a half dime, soldered 
to a thin rod of bismuth. The latter is contained in a small 
tube of hard rubber furnished with a handle. The disks 
are two in number : one is placed on the sound limb, the 
other on the corresponding part of the paralyzed limb. Both 
are in connection, by delicate silk-covered wire, with the poles 
of a galvanometer. If the temperature of both limbs be the 
same, the needle of the galvanometer remains quiet. If 
either be warmer than the other, the needle is deflected to 
the north or the south, according as one or the other limb 
has the higher temperature. By this apparatus, very much 
less than the hundredth of a degree of temperature can be 
determined with absolute certainty. 

Sensibility is not materially, if at all, lessened, though 
the reflex excitability is diminished, and often entirely abol- 
ished, from the very first. 

But the most obvious and important change is that which 
takes place in the paralyzed muscles, and which consists of 



ORGANIC INFANTILE PARALYSIS. 691 

atrophy and degeneration of the proper tissue. The process 
is very similar to that which constitutes the essential feature 
of progressive muscular atrophy, although it is far more 
rapid in its progress. 

With this atrophy, the electric contractility of the muscles 
disappears, although it has begun to be lost at an earlier 
period, and hence the strongest induced currents fail to 
cause the slightest contraction, and in some cases even pow- 
erful primary currents are equally inefficacious. Owing to 
the disturbance in the normal equilibrium of the muscles 
consequent on the paralysis, distortions of various kinds are 
produced, and hence we have the most important causes of 
club-feet. 

Causes. — Little is known of the etiology of organic in- 
fantile paralysis. In two cases under my observation, oc- 
curring in brothers, it was apparently induced by the nurse 
allowing the infants to lie on the damp ground for an hour 
or more ; in several other cases, it came on while the children 
were suffering from teething, and in others it has followed 
diseases of various kinds, such as whooping-cough, measles, 
scarlet fever, etc. In the great majority of the cases that 
have come under my observation, no cause could be reason- 
ably assigned. 

Diagnosis. — The symptoms of organic infantile paralysis 
are so characteristic, that there is no danger of its being 
mistaken for any other affection. 

Prognosis. — The prognosis depends very much upon the 
fact as to whether the disease has advanced so far as to have 
resulted in the abolition of the electric contractility of the 
affected muscles. If this is lost to the induced current, the 
cure will be difficult, and the treatment protracted ; if the 
primary current is also powerless, a cure is impossible. I 
believe I was the first to use the primary current in the 
treatment of infantile paralysis, and to insist on its great 
value as a curative agent, and as an element in the prog- 



692 DISEASES OF NERVE-CELLS. 

nosis. 1 If the muscles can be made to contract with either 
the induced or primary currents, the cure is merely a matter 
of time and patience. 

Morbid Anatomy. — The morbid anatomy of organic infan- 
tile paralysis is to be studied in the spinal cord, the nerves, 
and the muscles. As regards the latter, there has been a 
tolerable accord among observers, but there has been no ap- 
proach to uniformity relative to the state of the spinal cord 
and nerves. The general opinion has, perhaps, been that 
there is no appreciable alteration. In one case in which I 
had the opportunity of making a post-mortem examination, 
and of inspecting the condition of the cord, I found a cicatrix 
partially filled with a very small clot. The paralysis in this 
instance was situated in the left lower extremity, and had 
begun four years previously. The lesion existed in the 
lower part of the dorsal region in the left anterior column. 
No microscopical examination was made ; but, since the 
remarkable series of observations on the minute anatomy 
of the spinal cord, made by Dr. Lockhart Clarke, a new 
impetus has been given to studies of its morbid anatomy, 
and hence the results obtained in researches into the morbid 
anatomy of progressive muscular atrophy, glosso-labio-laryn- 
geal paralysis, locomotor ataxia, and other spinal affections. 
In organic infantile paralysis some recent observations have 
thrown light on its nature. MM. Charcot and Joffroy have 
had the opportunity of making a minute investigation in a 
case of infantile paralysis existing in a patient in the Salpe- 
triere — a woman who died at the age of forty. 

The disease began when she was seven years old. At 
first all the limbs were paralyzed, but by the end of a year 
the upper extremities had in a measure regained their 
power. The lower extremities remained nearly altogether 
without the power of motion. 

On post-mortem examination, the spinal cord was found 
to be affected from the cervical to the lumbar enlargement. 
1 New York Medical Journal, December, 1865. 



ORGANIC INFANTILE PARALYSIS. 



693 



The alterations were chiefly in the gray matter, and espe- 
cially in the anterior cornua. These were atrophied and 
distorted, and the cells had disappeared to a very great ex- 
tent. The posterior cornua, though involved, were affected 
to a much less extent. 

The anterior roots of the nerves coming from the dis- 
eased portions of the cord were atrophied. 

The paralyzed muscles had undergone fatty transforma- 
tion, and the fibrillae had, to a great extent, disappeared. 

From these examinations we perceive that the lesion in 
organic infantile paralysis consists essentially of atrophy and 
disappearance of nerve-cells. 

My own observations in the direction of the morbid 
anatomy of the disease under notice have been mainly 
limited to the condition of the muscles during life. 

The nature of the morbid process is well shown in the 
accompanying woodcuts, made from my own drawings of 
the microscopical appearances of portions of diseased mus- 
cles removed by Duchenne's trocar. Fig. 35 represents a 
portion of the upper part of the tibialis anticus muscle of a 



Fig. 35. 




boy who had suffered from organic infantile paralysis for 
over two years. Oil-globules are seen along the course of 
the fibrillge. These latter are irregular and torn, and the 
transverse striae are becoming dim. 

In Fig. 36 a still more advanced stage is shown. This 
cut represents a portion of the same muscle taken from the 



DISEASES OF NERVE-CELLS. 



lower part. The transverse striae have nearly disappeared, 
oil-globules are seen in large numbers, and fat-corpuscles 
are also abundant. 



Fig. 36. 




e9k 






IBtllfR 


* 



In Fig. 37 the progress of the disease is well shown. 



Ftg. 37. 




The upper margin of the specimen is a mass of fat-globules, 
and throughout the whole the transverse striae are absent. 

In Fig. 38 is shown a portion taken from the same mus- 
cle one month after the preceding specimens were removed. 




ORGANIC INFANTILE PARALYSIS. 695 

The transverse striae are entirely gone, and the muscle is a 
mass of oil-globules and fat- vesicles. 

Fig. 39 represents a piece of the same muscle six weeks 
later. It is now nothing more than a mass of connective 




tissue, the fat being almost entirely absorbed ; no transverse 
or longitudinal striae are to be perceived. 

But there is not, as Duchenne affirms, this degeneration 
in every case of organic infantile paralysis. In two cases, 
which had lasted over four years, I found the structure of 
the muscle unchanged. There were atrophy, loss of elec- 
tric contractility, and reduction of temperature, but every 
specimen of the affected muscles that I examined showed 
no change from the normal character. In every other re- 
spect the symptoms were similar to those observed in ordi- 
nary cases of the disease. Improvement was very slow, but 
finally every muscle except the rectus femoris in one, and 
the tibialis anticus in the other, recovered, and the children 
were enabled to walk. The affection in both cases was con- 
fined to the left lower extremity. 

I am hence led to the conclusion that fatty degeneration 
of muscles, though the ordinary result of organic infantile 
paralysis, is not an invariable consequence. 1 

Pathology. — It must be borne in mind that the disease 
under consideration is a paralysis primarily, and not an 

1 Journal op Psychological Medicine, No. 1, 1867, p. 57. Since the obser- 
vations then published, other observers have arrived at the same conclusion. 



DISEASES OF NERVE-CELLS. 

atrophy. There can be no doubt, therefore, that Duchenne 
is wrong in considering it, as he does, an acute form of pro- 
gressive muscular atrophy. In the first stage, the motor 
cells only are probably involved; in the latter, when the 
atrophy begins, the trophic cells are the starting-point. The 
disease is therefore, in my opinion, one which consists of 
atrophy, and disappearance of both motor and trophic ceUs, 
and hence we have, as its manifestations, paralysis and 
atrophy, each independent of the other. 

Moreover, there is no tendency in organic infantile pa- 
ralysis to extend beyond the limits of the muscles first par- 
alyzed ; on the contrary, there is a strong disposition toward 
repair of the spinal lesion, and the restoration of motility 
before the supervention of atrophy. These two features 
serve to increase the distinction between organic infantile 
paralysis and progressive muscular atrophy. 

Treatment. — The treatment of the disease consists in the 
use of general and local means. Of these, the latter are of 
much the greater importance, especially after the first or 
febrile stage has subsided, arid the disease is chiefly mani- 
fested in the paralyzed or atrophic condition of the muscles. 
During the acute stage, there is nothing of so much efficacy 
as rest in bed. I know of no medicines which are capable 
of producing any specific action on the spinal cord at this 
time, and, even after the spinal affection has become more 
chronic, the means mainly to be relied upon are those which 
are applicable to the local trouble of the muscles. 

Strychnia is useful because it is capable of acting as a 
general stimulant to the nervous system, and is, moreover, a 
tonic to the muscles. I generally prescribe it in union with 
iron and phosphoric acid, according to the following formula : 
]J. Strychnia sul. gr. j., ferri pyrophosph. 3ss., acidi phos- 
phorici §ss., syrup us zingiberis Jiiiss. M. ft. mist. Dose, 
a teaspoonful or less, according to the age of the child. 

The immediately local means of treatment are those 
which are calculated to promote the nutrition of the muscles, 



ORGANIC INFANTILE PARALYSIS. 697 

and restore or augment their contractile power. The first 
end is effected by causing a greater amount of blood to 
flow through the diseased parts, the second is best accom- 
plished by the persistent use of electricity, and active and 
passive exercise. 

Under the first head are embraced heat, friction, and 
kneading. 

Heat is best applied by means of hot water. A tempera- 
ture of from 110° to 120° Fahr. may be used, and the limb 
should be thoroughly immersed, and allowed to remain so 
for half an hour ; salt may be added to the water, with the 
view of augmenting the stimulant effect. 

Frictions with a dry towel, a flesh-brush, or the hand, 
are also exceedingly useful ; they should be practised several 
times in the course of the day, to the extent of reddening the 
skin. 

Kneading the muscles affords a means of exercising them, 
and of increasing the amount of blood in the vessels. They 
should be pinched firmly between the fingers of both hands 
to the extent of producing some little pain ; every paralyzed 
muscle should be gone over in this way daily. 

Under the second head, electricity comes first. If the 
induced current will produce contractions in the affected 
muscles, it should be employed ; but if, as often happens, it 
should fail to do so, the primary current must be brought 
into service. In the communication 1 already cited, I called 
attention to this valuable agent in the treatment of organic 
infantile paralysis. If a contraction can be induced by it, 
recovery is merely a matter of time. 

During the period from December, 1865, to December, 
1870, I have treated ninety-eight cases of organic infantile 
paralysis. Of these, the disease was so far advanced in eleven, 
as to render it very evident, after thorough examination, that 
success was out of the question. In the remaining eighty- 
seven, no contractions could be caused in the affected mus- 

1 New York Medical Journal, December, 1865. 



698 



DISEASES OF NERVE-CELLS. 



cles by the strongest induced currents in thirty-nine ; while 
in all of these the primary current produced decided con- 
tractions. Of the eighty-seven cases, fourteen were entirely 
cured ; twenty-eight were greatly improved ; thirty slightly 
improved, and the remainder — fifteen — discontinued treat- 
ment before sufficient time had elapsed to ascertain the 
effect. 

At the best, however, the treatment must be of long 
duration, and even when the muscles are entirely restored 
they must be reeducated to the performance of their func- 
tions. Few parents, comparatively, have the patience to 
wait and to devote the necessary time to doing their part 
of the work ; unless there is a reasonable assurance in regard 
to these points, it is better not to undertake the case. It is 
not, except in recent cases, a matter of days, or of weeks, but 
of months, and sometimes of years. 

But, even when fatty degeneration is going on, the disease 
may be arrested by the proper use of the direct current. Fig. 
40 shows the appearance of a portion of muscle as exam- 



Fig. 40. 




ined by the microscope, October 21, 1866. This specimen 
was removed from the belly of the gastrocnemius muscle 
before any treatment whatever had been employed, and 
after the disease had existed, with gradually-advancing atro- 
phy, for about four and a half months. 



ORGANIC INFANTILE PARALYSIS. 699 

Fig. 41 represents a piece of the same muscle from 
the same part, on December 3d, six weeks after the treat- 
ment was begun. In the first, oil-globules are seen to have 
displaced the muscular tissue to a great extent ; the trans- 

Fio.41. 




verse strise have disappeared entirely from some parts, and 
are faintly seen even where they are present. In the second, 
the quantity of fat is perceived to be very much lessened, 
and the striae are much more numerous and distinct. This 
case, which was one of paralysis of the left leg and foot, 
entirely recovered. 

After the power of the will is to some extent restored 
over the muscles, the induced current may be used with more 
advantage than the direct. 

Along with the electricity, passive motions of the joints 
should be made, and the child should be encouraged to direct 
the will to the affected muscles as often and as powerfully 
as possible. 

HYPERTROPHY OF MUSCULAR CONNECTIVE TISSUE. 

The first to call attention to this affection was Du- 
chenne, 1 who described it under the name of paraplegie hy- 
pertrqphique de Venfance de cause cerebrcde. He has since 
designated it paralysie pseudo-hypertrophique, ou myo-scle- 
rosique? Jaccoud 3 calls it sclerose musculaire progressive 

1 De l'Electrisation localisee, etc., Paris, 1861, p. 353. 
s Archives Generates, etc., 1868. 8 Op. cit., p. 365. 



700 DISEASES OF NERVE-CELLS. 

(progressive muscular sclerosis). Dr. Foster 1 terms it pa- 
ralysis with apparent muscular hypertrophy. 

Begarding the affection as consisting essentially in dis- 
ease of the motor and trophic nerve-cells, and as being mani- 
fested by hypertrophy of the muscular connective tissue at 
the expense of the muscular fibres, I have provisionally 
placed it in the present chapter. My personal acquaintance 
with the disease is limited to one case, and I am of the 
opinion that it is exceedingly rare in this country — one other 
case only having been reported, by Drs. William Ingalls and 
S. Gr. Webber, of Boston, 2 the latter of whom, in connection 
with the history of the case, has written a very excellent 
memoir on the disease. 

Symptoms. — The first symptom observed is weakness in 
the lower extremities, which causes an inability to stand 
steadily, or to walk without stumbling or falling. The legs 
are separated widely in standing or walking, and thus a pe- 
culiar character is given to the gait, which somewhat resem- 
bles that of a duck. 

Yery soon an enlargement of the calf of one of the legs 
is perceived, the other before long is affected, and then the 
muscles of the thighs and gluteal region become involved. 

As the child stands or walks, a remarkable incurvation 
of the spine in the lumbo-sacral region is perceived, so that, 
if, as Duchenne remarks, a plumb-line be allowed to fall 
from the most posterior spinous process of a vertebra, it 
passes far behind the sacrum. He considers this phenome- 
non to be due to weakness of the erector muscles of the 
spine. The muscles of the trunk may become involved, as 
may also those of the upper extremities — the deltoids being 
the first affected in the majority of cases, and the progress 
being much slower than in the lower extremities. 

With the advance of the hypertrophy the paralysis 

lancet, May 8, 1869. 

2 A case of Progressive Muscular Sclerosis, with a Paper on the same. Bos- 
ton Medical and Surgical Journal, November 17, 1870. 



ORGANIC INFANTILE PARALYSIS. 701 

becomes more strongly marked, and finally the child is 
confined to the recumbent posture. Distortions from dis- 
turbance of muscular equilibrium may take place, and the 
attempt at flexion or extension becomes painful. 

Electric contractility is always lessened to the induced 
current, but, according to some observers, is increased to 
the primary current. In the case under my care, both cur- 
rents failed to cause the normal amount of contraction in 
the affected muscles. The cutaneous sensibility is not 
affected. 

The course of the disease is slow, its average duration 
being about five or six years. As it advances, there are 
symptoms indicating loss of mental power, and cerebral 
disturbance is sometimes also indicated by ocular troubles 
and pain in the head. 

Death takes place by the respiratory muscles becoming 
implicated, by exhaustion, or by some intercurrent affec- 
tion. 

In the case which came under my notice March 7, 1871, 
and which is still under treatment, the patient, a boy seven 
years old, exhibited great disinclination to learn to walk. 
At three years of age he could not stand longer than a few 
seconds, and even for this time he was obliged to spread the 
legs apart and to hold on to some article of furniture. It 
was not noticed till he was ^.\e years old that his legs were 
larger than was natural. The hypertrophy began in the 
right calf, then attacked the left, and then the glutei mus- 
cles, before affecting the muscles of the thighs. The upper 
extremities are as yet unaffected, but the spinal curve is 
very evident. The accompanying woodcuts (Figs. 42 and 
43) give a posterior and profile view of this boy, from pho- 
tographs. He was unable to stand alone while the photo- 
graphs were being taken, but the spinal curve is well shown, 
and the positions are those he spontaneously assumed. 

Causes. — The disease is almost entirely confined to in- 
fancy, and boys are more liable than girls. From a table 



702 



DISEASES OF NERVE-CELLS. 



containing analysis of forty-one cases given by Dr. Webber 
in his paper already cited, it appears that in one case the 
patient was twenty-six when the disease began, in one a few 



Fig. 42. 



Fig. 43. 




years under forty, and in one about twenty-eight. It is 
possible that those cases occurring in persons of adult age 
were instances of the simple hypertrophy of an extremity, 



ORGANIC INFANTILE PARALYSIS. 703 

such as the case reported by Mr. Maunder, 1 and similar ones 
by other authors. 

All the cases collected by Dr. Webber, except five, oc- 
curred in males. 

There is some reason to suspect hereditary influence as 
an occasional predisposing cause. 

Of the exciting causes nothing is known with any cer- 
tainty. 

Diagnosis. — The only affection at all resembling that un- 
der consideration is simple muscular hypertrophy due to an 
excessive supply of blood being sent to a part of the body. 
The histories and phenomena of the two disorders are, 
however, so very different, that I do not see how any error 
can arise in making a diagnosis between them. 

Prognosis. — The prognosis is unfavorable. A case of re- 
covery is related by Duchenne, and other observers have 
reported improvements, but the tendency is to death, though 
life may be prolonged many years notwithstanding the 
gradual advance of the disease. 

Morbid Anatomy. — The spinal cord has only been exam- 
ined in one case — that of Eulenburg, by Cohnheim — and 
no lesion was discovered. We are not, from this negative 
result, to infer that changes had not taken place. About 
the same time observers were everywhere declaring that in 
progressive muscular atrophy, organic infantile paralysis, 
and locomotor ataxia, there were no central lesions. I have 
no doubt that careful microscopic examination of the spinal 
cord, after the manner of Dr. Lockhart Clarke, will result 
in the detection of atrophy and degeneration of nerve-cells 
in cases of hypertrophy of muscular connective tissue. 

Examination of the muscles, however, gives very uni- 
form results. The proper tissue is atrophied and has under- 
gone degeneration, while the connective tissue has not only 
taken its place, but has undergone extensive proliferation. 

In the case under my care I have made repeated exami- 

1 Medical Times and Gazette, March 27, 1869- 



704 



DISEASES OF NERVE-CELLS. 



nations, removing the muscle with the trocar of Duchenne. 
The accompanying woodcut (Fig. 44) represents the histo- 



Fig. 44. 




logical character of a portion of muscle taken from the left 
gastrocnemius. The transverse striae are seen to have 
entirely disappeared, the fibrillae are in a state of disin- 
tegration, and the connective tissue is present in large 
amount. 

Pathology. — The main point of difference between hyper- 
trophy of the muscular connective tissue and organic infan- 
tile paralysis is that, in the former there is muscular atrophy 
with connective-tissue hypertrophy, while the latter is atro- 
phy without this complication. It is highly probable that 
the lesion in the former is analogous to that in the latter 
disease. They are certainly not identical, but the phe- 
nomena of hypertrophy of the muscular connective tissue 
indicate the lesion to be situated in the motor and trophic 
cells. 

Treatment. — The induced current has been useful in Du- 
chenne's hands, and, as stated, he has reported one cure. 
He combines with it shampooing or kneading, and hydro- 
therapeutics. The primary current to the spinal cord and 
sympathetic nerve has been used by Benedikt x in five cases, 

1 Electrotherapie, Wien, 1868, p. 186. 



ORGANIC INFANTILE PARALYSIS. 705 

and in three of them the induced current was applied to 
the hypertrophied muscles. Three cases were improved. 

In my case the primary current is being used to the 
spinal cord and sympathetic nerve, and the induced to the 
affected muscles. These latter are also well kneaded every 
day. At the end of three weeks I am unable to detect any 
improvement. 
45 



CHAPTER IV. 

FUNCTIONAL DERANGEMENTS OF MOTOR NERVE-CELLS. 
PARALYSIS AGITANS. 

Under the term paralysis agitans, several affections have 
been included which are very different in character. 1 
have already considered two of them — multiple cerebral 
sclerosis and cerebro-spinal sclerosis; a third I propose to 
treat of under the name of paralysis agitans. Though the 
objections to its use are many, it possesses the advantages 
of being already known, and of expressing two of the main 
features of the disease to which it is applied. 

The affection which Parkinson 1 described, and to which 
he applied the name " shaking palsy," has since been very 
carefully studied by many writers, and the fact has been 
clearly made out that it is not a single disease. 

Charcot, in numerous memoirs and lectures to which 
reference has already been made, has very definitely shown 
that the affection which he designates sclerose en plaques 
disseminees — considered in this treatise under the name of 
cerebro-spinal sclerosis — must be regarded as a distinct 
morbid condition ; and in the first section of this work I 
have made the same claim for multiple cerebral sclerosis. 
The term paralysis agitans I apply to a very different affec- 
tion from either, but one which I am confident will be 
recognized as presenting well-defined characteristics. Or- 
denstein 2 has included it with multiple cerebral sclerosis, 

1 Essay on the Shaking Palsy, London, 1817. 

2 Sur la Paralysie agitante etla Sclerose en plaques generalisee, Paris, 1868. 



PARALYSIS AGITANS. 707 

and denies it any fixed seat ; but Jaccoud * locates it in the 
pons Varolii, without, however, in my opinion, having any 
good reason for so doing. Of all writers Dr. Handfield 
Jones a appears to have the clearest ideas of the affection 
now nnder notice. Thus he says : 

" It appears to me a question whether two distinct affec- 
tions are not often comprehended under this name. For on 
the one hand it appears pretty certain that there is one form 
which is met with in old persons, is quite incurable, and 
is associated with, if not dependent on, organic wasting 
changes in the nervous centres ; while another form occurs 
in younger persons, is more curable, and therefore is pre- 
sumably not dependent on organic change." It is this latter 
disease which I propose to consider at present. The other 
embraces cases of multiple cerebral sclerosis and cerebro- 
spinal sclerosis. 

Symptoms. — The primary manifestation is tremor, and 
this, like the same symptom in the severer forms of disease 
already considered, in which it forms an essential feature, 
may begin in a very restricted or more extensive region of 
the body. It is present whether voluntary movements are 
performed or not with the affected limbs, but is increased 
by mental excitement of any kind, by physical exertion, or 
by any cause capable of depressing the powers of the system. 

It is not generally the case that the tremor shows any 
tendency to advance much beyond its original limits, how- 
ever small or extensive these may be. When it does exhibit 
such a disposition, contiguous muscles are first attacked, and 
then the corresponding ones on the opposite side of the body. 

From the very first there is muscular weakness, not to 
any very great extent, but still sufficiently evident to care- 
ful examinations with the dynamometer. As the tremor 
increases in violence or extent, the paralysis becomes more 
obvious. 

1 Op. cit., p. 424. 

2 Studies on Functional Nervous Disorders, LondoD, 1870, p. 382. 



708 DISEASES OF NERVE-CELLS, 

Sensibility is rarely affected, there is no bending of the 
body forward, no festination, and no head-symptoms. The 
tremor always ceases during sleep, except in very extreme 
and long-continued cases, and there may be intermissions 
of longer or shorter duration while the patient is awake. 

Causes. — Paralysis agitans may result from emotional 
disturbance, from continuous or severe muscular exertion, 
from some exhausting disease, such as dysentery, typhoid or 
typhus fever, or rheumatism, or from blows, falls, or other 
injuries. In many cases the cause cannot be ascertained. 

Of twenty -one cases of which I have records, six were 
apparently due to mental causes, four to excessive physical 
exertion, four to diseases of various kinds, two to injuries, 
and in five no cause could be discovered. 

Two cases of mercurial trembling, the symptoms of 
which affection are very similar to those of non-toxic paraly- 
sis agitans, are not included among the foregoing. 

Diagnosis.— From multiple cerebral sclerosis, paralysis 
agitans is distinguished by the facts that there are no head- 
symptoms, no festination, and no derangements of sensibility. 
It is more apt to occur in persons under the age of fifty, and 
may be met with in quite young persons. The reverse of 
both these circumstances is true of multiple cerebral sclerosis. 

From cerebro-spinal sclerosis, it is diagnosticated mainly 
by the absence of any head-symptoms, by the fact that the 
tremor usually comes on before the paralysis, and is inde- 
pendent of voluntary movements. 

The character of the muscular action, and the history of 
the case, will prevent its being confounded with chorea. 

Prognosis. — Paralysis agitans rarely terminates fatally, 
and when it does it is because the tremor has become so 
general that death results from exhaustion. It, however, 
often happens that all measures fail to relieve the agitation. 
Of the twenty-one cases occurring in my own experience, 
six were cured, four partially so, and in the rest no per- 
manent effect was produced by any means I employed. 



PARALYSIS AGITANS. 709 

Morbid Anatomy and Pathology. — Nothing is known of the 
morbid anatomy. In a few cases, patients have died either 
from the disease or from some intercurrent affection, and post- 
mortem examinations have been made with negative results. 
Petrseus, quoted by Dr. Handfield Jones, relates two severe 
cases, one of which proved fatal. At the autopsy nothing 
was found but fatty degeneration of the heart and pneumonic 
consolidation of the right lung. He remarks on the tremor 
not being constant in many cases, ceasing for some days and 
then returning with fresh force, or changing its seat from 
one part to another. 

In my opinion, the disease under consideration is due to 
an irregular and diminished evolution of nerve-force from 
the motor nerve-cells in relation with the nerves supplying 
the muscles in which the agitation exists. The pathology 
of tremor, not the result of structural lesions, is a subject 
which is beginning to be studied, but which is not yet clearly 
understood. We know that, when we have strongly exerted 
an arm, for instance, the muscles are tremulous for some time 
afterward, and that the agitation is rendered very evident 
when we attempt to write or do any otner act requiring deli- 
cate muscular adaptation. A period of rest must take place 
before steadiness is regained. Now, in such a case the agita- 
tion is not probably due to any cause inherent in the muscle, 
but is the result of exhaustion in the nerve-cells and the dis- 
engagement of insufficient force in an intermittent manner. 
I suppose paralysis agitans to be due to some such action in 
the motor nerve-cells in the gray matter of the spinal cord. 

Treatment. — I have used electricity, both of the galvanic 
and faradaic kinds, in all the cases of paralysis agitans that 
have been under my charge, and in conjunction have 
employed many internal medicines, such as arsenic, iron, 
manganese, zinc, copper, phosphorus, strychnia, and seda- 
tives of various kinds, including opium, bromide of potas- 
sium, conium, stramonium, Indian hemp, and many others. 
I am very decidedly of the opinion that the best treatment 



710 DISEASES OF NERVE-CELLS. 

consists in the use of the constant primary current to the 
spinal cord, sympathetic nerve, and the affected muscles, 
while at the same time strychnia and phosphorus, according 
to the formula given on page 58, are administered internally. 
By these means two of my six successful cases were en- 
tirely cured within two months. One of these was sent to 
me by my friend Dr. F. 1ST. Otis. The affection was con- 
fined to the right arm, and was probably due to inordinate 
gymnastic exercise ; the other was a gentleman from St. 
Louis, in whom the disease was also confined to the right 
arm, and had apparently resulted from writing excessively. 
Both had lasted several months. 

The four other cases were, two of them, consequent on 
other diseases, and two were without known cause. Three 
were women ; the tremor in two was in both arms, and in 
two, in one leg in each. The duration of the treatment was 
from three to seven months. A full and nutritious diet, and 
the avoidance of all mental excitement or strong physical 
exertion, are important features in the treatment. 

In the mercurial form of the disease the iodide of potas- 
sium in large doses — twenty grains three times a day — must 
be administered in conjunction with the other remedies. 



The disorder, which I think is best named writer's spasm, 
has been variously designated, according to the prominence 
which each author on the subject has given to some one 
symptom. Thus it has been called scrivener's palsy, writer's 
cramp, chorea scriptorum, mogigraphia, writer's dyskinesia, 
etc. 

By the majority, if not by all writers who have given it 
a fixed seat, it is regarded as being a disease of the periph- 
eric nerves. A consideration of its mode of origin and 
symptoms must, I think, tend to show that it is an affection 
of the motor nerve-cells, similar in several respects to paral- 
ysis agitans. 



PALALYSIS AGITANS. ?H 

Although in my nomenclature of the disease I have 
termed it writer's spasm, I have done so simply for the sake 
of convenience, and because the affection is more frequent- 
ly met with among writers than other professional people. 
It does, however, occur among those who are required by 
any employment to perform delicate, complex, or uniform 
actions with the fingers for many hours each day. It is thus 
not uncommon among violinists, pianists, watch-makers, 
jewellers, seamstresses, etc. The account I shall give of the 
affection, though specially applicable to writers, will be rele- 
vant to those of other professions who may suffer from this 
singular disease. 

Symptoms. — The first symptom usually observed is a feel- 
ing of fatigue experienced in the muscles of the hand, fore- 
arm, arm, and shoulder. The thumb is especially affected, 
and is also often the seat of a dull, aching pain. Pains not 
very severe nor fixed are also common in the muscles higher 
up. This fatigue the patient endeavors to correct by grasp- 
ing the pen more firmly, and by making an increased men- 
tal effort to regulate the muscular contractions. But he 
only thereby adds to the difficulty, for the weariness and 
pain are increased, the muscles become weakened, and, 
moreover, irregular and incoordinate actions ensue, which 
render the writing more or less unreadable. 

If he perseveres day after day in his occupation he soon 
reaches that stage of the disease in which the ability to 
direct the pen in accordance with his will is lost, and the 
automatic actions, which are of great importance in writing, 
are likewise very much diminished. For a time, then, he 
writes better when his mind is not occupied in directing the 
formation of every letter, but in which he allows the muscles 
as it were to take care of themselves. Constantly, however, 
he feels the necessity of mental action, and this action inva- 
riably increases the difficulty, until at last, the moment the 
attempt is made to write, the pen, actuated by the muscles of 
the fingers, executes such disorderly movements as to bear 



712 



DISEASES OF NERVE-CELLS. 



no analogy with the words attempted to be written. A dis- 
tinct paroxysm is thus induced, which lasts as long as the 
patient persists in the attempt to write. "When he discon- 
tinues, the spasm ceases, and he can perform any other act 
with the fingers without there being the slightest convulsive 
movements. In some cases there is pain in the fingers, the 
muscles between the metacarpal bones, and in those of the 
forearm. The spasm is much worse if the patient be excited 
or particularly anxious to do his best. 

In the accompanying woodcut (Fig. 45) are represented 
three attempts of a patient to write the name " James Ely." 

Fig. 45. 




At first some resemblance to the letter J is made 3 but in the 
second trial it is less distinct, and in the third is lost alto- 
gether. 

I have witnessed eleven cases of this disease during the 
past six years — all of them in writers except one, an interest- 



WRITER'S SPASM. 713 

ing case occurring in an engraver. This patient was seized 
with the spasm in the lingers of the right hand whenever he 
grasped his burin. He could write for hours perfectly well. 

In three of the other cases the individuals had acquired 
the power to write with the left hand, but the spasm soon 
appeared in it on any attempt at writing. 

All of my patients had resorted to various expedients to 
obviate the spasms, under the idea that they were produced 
by metallic pens carrying off the electricity from the arm ; 
several had, for a time, made use of quills, or hard rubber 
pens, and for a time relief had been obtained, but the par- 
oxysms soon became as bad as ever. Others had used very 
thick pen-holders, and this expedient was also, for a time, 
successful. In the end, however, all such efforts to prevent 
the spasms proved futile. 

In two cases there were other symptoms, indicative of 
disorder of the central nervous system. These consisted of 
headache, pain in the back, and occasional tremors in the 
limbs. 

Causes. — The disease is more apt to attack persons some- 
what advanced in life, than the very young. All my pa- 
tients were over forty years of age. All were males, though 
this proclivity of men to the affection is not absolute, as 
several cases are on record in which women, seamstresses 
especially, have been its subjects. It is apparently some- 
times induced by using the fingers in constrained positions. 
In one of my cases, the patient, who had been in the habit 
of writing with the hand supported by the little finger, 
cured himself by allowing the whole hand to rest on the 
desk. The principal cause — the habitual performance of 
certain restricted movements — has already been sufficiently 
considered. 

Diagnosis. — Attention paid to the characteristic symp- 
toms of writer's spasm will prevent its being mistaken for 
lead-paralysis, progressive muscular atrophy, or any other 
disease. 



714 DISEASES OF NERVE-CELLS. 

Prognosis. — In the early stage, writer's spasm admits of 
cure. When it has existed a long time, and when the patient 
cannot rest, a cure is almost impossible. 

Of the eleven cases that have been under my care, seven 
were incurable, having lasted several years, and resisting all 
means of cure, even long rest. Of the other four, one was 
in process of cure by his own expedient of changing the atti- 
tude of the hand in writing, when he came under my obser- 
vation. The remaining three cases were successfully treated 
by means to be presently described. 

Morbid Anatomy and Pathology. — As regards the morbid 
anatomy, there are no data, and the lesion is probably not 
one which can be detected by our present means of obser- 
vation. The affection is, however, doubtless due to disorder 
in the normal action of the motor-cells, and this disorder is 
the result of over-exertion of a particular set of muscles in a 
particular way. Examples of cerebral exhaustion by the pre- 
dominance of one idea, or a series of ideas for a long time, 
are often witnessed. Writer's spasm is, I conceive, the result 
of a similar action on spinal motor cells. 

Treatment. — The most indispensable means of cure is 
rest, and, unless this can be secured, it is useless for the phy- 
sician to undertake the treatment. In some cases it has 
succeeded without any assistance. The abstinence from 
writing should be absolute during at least six months. 

The constant galvanic current has proved the most effect- 
ual agent in my hands ; I apply it to the sympathetic nerve, 
the spinal cord in its upper part, and to all the muscles and 
nerves of the upper extremity. A half an hour three times 
a week, with a current of considerable intensity (forty cells), 
will be sufficient. Faradization, in my experience, is more 
productive of harm than benefit. 

With the galvanism I have administered the combination 
of phosphide of zinc, and extract of nux- vomica, recom- 
mended on page 58 of this treatise. 

When a cure cannot be effected, well-devised prothetic 



LEAD PARALYSIS. 715 

apparatus will enable the patient to write. Division of ten- 
dons or muscles is not admissible. 

LEAD PARALYSIS. 

The frequency with which lead paralysis is met with, 
and the fact that the loss of power in certain muscles is gen- 
erally unaccompanied by symptoms referable to the system 
at large, must be my excuse for including it within the limits 
of the present treatise. 

Symptoms. — Before the occurrence of paralysis, the patient 
has probably suffered from attacks of lead-colic, though this 
is not invariably the case. The immediately precursory 
symptoms connected with the loss of power are slight numb- 
ness and tremors in the muscles of the upper extremities. 
Occasionally, the muscles of the trunk and lower extremities 
become involved in the trembling. 

Ere long the patient observes that he has difficulty 
in extending the fingers or wrist, and that there is a general 
loss of strength in one or both hands. These symptoms go 
on increasing in severity, and eventually he loses the power 
to raise the hand or fingers. In extreme cases, the ability 
to extend the forearm, or to raise the arm from the side, is 
lost through the paralysis of the triceps and deltoid. Occa- 
sionally, the extensors of the lower extremity are involved 
in the paralysis. 

The predominance of the loss of power in the extensors 
has led to the idea that they alone are affected. The drop- 
ping of the hand, the flexion of the forearm on the arm, the 
hanging of the arm against the side of the body, and, when 
the* lower extremity is affected, the inability to raise the toes 
so as to avoid striking them against the ground in walking 
all give countenance to this supposition. But careful ob- 
servation shows that the difference is merely one of degree, 
and that there is a very considerable loss of power in the 
flexor muscles. Indeed, of many cases of the disease that I 
have observed in hospital and private practice, I have never 



716 DISEASES OF NERVE-CELLS. 

seen one in which the flexors were not implicated with the 
extensors. 

Owing to the disuse of the muscles, atrophy takes place, 
and this is frequently exceedingly well marked, and, from 
the disturbance of the normal equilibrium between the sev- 
eral groups of muscles, contractions and distortions ensue. 
The circulation in the affected limbs becomes languid and 
weak, and painful swellings result in consequence. 

It is generally supposed that the right arm is more gen- 
erally affected than the left ; such, however, does not appear 
to be the case. Thus, Tanquerel des Planches, 1 of seventy- 
nine cases in which the upper extremities were the seat of 
the paralysis, found both affected in fifty-one, the left twenty- 
three times, and the right twenty-four. Of thirty-two cases 
of lead-paralysis occurring in my own practice, the upper 
extremities were affected in all ; in twenty-seven both limbs 
were the seat ; and, of the remaining five, three were in the 
left, and two in the right. The left upper extremity was 
therefore affected thirty times, and the right twenty-nine. 

In some cases, the muscles of respiration become very 
seriously paralyzed through the influence of lead, and death 
then soon takes place. In two of my cases there was aphonia, 
and in several the voice was materially weakened. 

The electric sensibility and contractility are always 
greatly reduced in all cases of lead paralysis. In the major- 
ity of cases, no faradaic current, which it is safe to employ, 
will produce contractions, and strong primary currents are 
necessary. The cutaneous sensibility is rarely impaired. 

The saturnine cachexia is almost always present, and 
the blue line on the gums can. readily be distinguished. 

Causes. — The fact that paralysis follows the introduction 
of lead into the system admits of no doubt. This introduc- 
tion may take place through the stomach, the air-passages, 
or the skin. The two latter are the more common channels 
for contamination. 

1 Traite des Maladies de Plomb. Paris, 1839, t. ii., p. 39. 



LEAD PARALYSIS. 717 

It is, of course, more frequently encountered among those 
who work in lead, such as lead founders and smelters, the 
makers of white and red lead, painters, plumbers, printers, 
etc. ; although it may occur among those who are only tem- 
porarily or accidentally exposed to the toxic influence. Thus, 
it may be caused by drinking water which has passed through 
lead pipes, or been kept in lead vessels, by using tobacco 
which has been wrapped in lead foil, two cases of which 
have happened in my experience, 1 and which is so common 
a cause that, in France, Belgium, and Prussia, strong laws 
have been passed against packing tobacco in lead ; by the 
use of hair-dyes containing lead, of which I have seen three 
cases; the use of powders and enamels for the face, two 
cases of which I have observed, one in consultation with my 
friend Prof. Lewis A. Say re ; and by several other less com- 
mon causes. The majority of cases, however, occur in paint- 
ers, probably for the reason that workers in white and red 
lead, though more exposed, are aware of their danger, and 
take effectual measures to prevent absorption. 

Diagnosis. — The history of the case, including a knowledge 
of the occupation of the patient, will generally prevent any 
error in diagnosis. The presence of the peculiar cachexia, 
the existence of the blue line around the gums, and the pre- 
dominance of the paralysis in the extensors, especially those 
of the wrist, will tend still further to render the diagnosis 
accurate. 

Prognosis. — The prospect of recovery depends altogether 
on the ability to produce contractions in the paralyzed mus- 
cles by electricity. If the induced current will effect them, 
the cure will be rapid, if the interrupted primary current is 
required, a longer time must elapse before success is attained ; 
but, if the muscles will not react to either the induced or 
primary currents, a favorable result is not to be expected. 

1 See my translation of Meyer's Electricity in its Relations to Practical Medi- 
cine, New York, 18*70, p. 181, for reference to other cases. 



718 DISEASES OF NERVE-CELLS. 

The extent of the atrophy is also an important element in 
the prognosis. 

Morbid Anatomy and Pathology. — So far as the central 
nervous system is concerned, no spinal lesions have been 
found unless in those cases complicated with cerebral symp- 
toms, and when inflammation and softening have existed. 
The difficulty is one which probably affects the motor nerve- 
cells of the spinal cord, and this in a way to be undiscov- 
erable — as much so as the effects of opium, alcohol, hydro- 
cyanic acid, strychnia, and other substances — by our present 
means of investigation. 

The muscles have been examined by Andral, 1 Gendrin, 2 
and Tanquerel des Planches, 3 and analogous results obtained. 
The fibres have been found to be pale and yellowish, to be 
friable, atrophied, and desiccated. I have repeatedly re- 
moved small portions with Duchenne's trocar, and have al- 
ways found the transverse strias disappearing, and fatty 
degeneration making its appearance. . 

The hypothesis, that the affection is, primarily, one of the 
muscles, is not supported by facts. Such a' thing as muscular 
paralysis independent of nervous derangement somewhere 
is unknown in the whole range of pathology. And those 
cases of apparent loss of muscular irritability, resulting from 
certain poisons, adduced by Longet, Bernard, Mitchell, my- 
self, and others, were simply instances in which the loss of 
nervous irritability took place from the periphery to the 
centre. The present state of our neurological knowledge 
is altogether against the idea of muscular irritability inde- 
pendent of the nerves. When a muscle is no longer capable 
of contracting, it is because the nerves are dead. 

Facts, too, are against the notion that the lead acts by 
contact with the muscles, and the circumstance of the pa- 

1 Clinique Medicale, t. ii., p. 227. 

8 Maladies de l'encephale, par Ahercrombie, traduction, seconde edition, 
p. 576. 

8 Op. cit., pp. 77, 144, 149. 



LEAD PARALYSIS. 719 

ralysis occurring so generally in the hands of painters, for 
instance, is adduced in proof. But we have seen that the 
left hand is just as frequently affected as the right, while it 
is certainly less in contact with the lead. Moreover, those 
cases of paralysis in the extensors of the hand, which have 
resulted from hair-dyes and other cosmetics, are altogether 
against the hypothesis in question. 

Treatment. — The first thing to do in the treatment of a 
case of lead-paralysis is to remove the lead from the system. 
This is done by the administration of the iodide of potassium, 
through the agency of which the mineral is converted into 
a soluble compound, the iodide of lead, which is excreted 
from the system, mainly by the kidneys. Some authors ad- 
vise caution in the use of the iodide of potassium, on the 
ground that the resulting compound is very poisonous, and 
may produce highly-deleterious effects. In a great many 
cases of lead-paralysis and other consequences of lead-poi- 
soning in which I have given the iodide, I have never seen 
the least untoward result, and I always use it in large doses 
from the beginning. In many cases the lead can be readily 
detected in the urine. If there is great debility, or if the 
cachexia be marked, iron, quinine, and strychnia, may be 
employed with advantage. 

But with all these measures the paralysis remains, and 
would continue indefinitely, without the use of measures 
directed specially against it : chief among these is electricity. 
The induced current, if it will cause the muscles to contract 
is to be preferred. Each paralyzed muscle must be acted on 
for two or three minutes every alternate day, so that for 
both upper extremities the duration of a seance would vary 
from a half to three quarters of an hour. In ordinary cases 
two months will suffice to effect a cure. 

But it often happens that the electric contractility of the 
paralyzed muscles is so completely abolished that the induced 
current is without effect. In such cases the primary inter- 
rupted current must be used, and continued till, as will 



720 DISEASES OF NERVE-CELLS. 

eventually be the case, the induced current causes contrac- 
tions. I have never seen a case in which the primary cur- 
rent would not produce contractions. One of the worst 
examples of the affection in question I ever saw is the 
patient who formed the subject of a recent clinical lecture 
to the class at the Bellevue Hospital Medical College. 1 His 
improvement under the circumstances has been rapid, and 
he is now (March 31st) able to earn his living again. In- 
duced currents of great power failed to produce contractions, 
and but for the use of the primary current he would have 
been incurable. 

If the primary current fails to act on the muscles, success 
is out of the question. 

In addition to electricity, frictions, kneading the muscles, 
and passive exercise, are useful. Contractions may be over- 
come by suitable prothetic apparatus. In a case under the 
care of Prof. Sayre, and which I had the opportunity of see- 
ing, the patient, a young lady, was able to play the piano 
— though paralyzed in both hands — by means of an admira- 
ble appliance devised by Dr. E. D. Hudson, of this city. 

1 Jouenal op Psychological Medicine, January, 1871, p. 43. 



SECTION V. 
DISEASES OF PEEIPHEEAL JEEVES. 



I do not propose to include under this head all the dis- 
eases to which the peripheral nerves are liable, but to take 
one or more as types of others which are different merely 
from their situation. Thus, any nerve of the body may be 
paralyzed from injury or disease, or from some contiguous 
affection capable of interfering with the due performance of 
its functions. It would be useless to give such paralyses sep- 
arate consideration, as their general features and the treat- 
ment proper can be sufficiently pointed out under the head 
of a typical representative. 

Besides, many affections, which are often regarded as 
located in the peripheral nervous system, are really central 
in situation. Among them are various cases of paralysis, 
spasm, hyperesthesia, and anaesthesia, which have already 
been considered as symptoms of centric diseases. 

I shall divide the affections of the peripheral nerves into 
four groups: paralysis, spasm, anaesthesia, and hyperses- 
thesia. 

46 



CHAPTEK I. 

PERIPHERAL PARALYSIS. 
FACIAL PARALYSIS. 

Paralysis of the facial nerve has already been considered 
as a symptom of several central lesions, but it may exist as 
an affection of altogether peripheral origin. As such, it is 
often known as Bell's paralysis, on account of its real nature 
having been first clearly pointed out by Sir Charles Bell. 
The nerve in question, the facial or portio-dura of the sev- 
enth pair, was, at one time, regarded as one of sensation, 
and, in accordance with this view, was often divided for 
neuralgia. The experiments of Bell and Magendie estab- 
lished the fact of its being entirely a nerve of motion. 

Symptoms. — The facial nerve is distributed to nearly 
every muscle of the face. Its paralysis therefore causes such 
decided change of expression as to be readily recognizable. 
The most marked phenomenon, and one which is of impor- 
tance in the diagnosis, is the inability to close the eye of the 
affected side. This is due to the fact that the orbicularis 
palpebrarum has lost its contractile power, while the leva- 
tor palpebrse superioris, not supplied by the facial, but by 
the third nerve, .is not paralyzed, and keeps the upper lid 
elevated. In consequence of this condition, the eye is con- 
stantly exposed to the action of the atmosphere, and to con- 
tact with extraneous substances. The patient cannot wink, 
and thus the tears, not being distributed over the surface of 
the eyeball or carried off by the nasal duct — the tensor tarsi 



PERIPHERAL PARALYSIS. 723 

also being paralyzed — run over the lower lid, and scald the 
cheek. From this inability to wink, dust and other small 
particles of matter are not removed, and hence considerable 
irritation is produced. Exposure to strong light or to wind 
adds to the inconvenience. Comparative comfort may be 
obtained by the patient frequently closing the eye with the 
finger, or by keeping the lids together with a piece of adhe- 
sive plaster. 

The next most prominent group of symptoms is due to 
the loss of power in one lateral half of the orbicularis oris. 
As a consequence, the patient cannot purse up the mouth on 
that side, as in the act of whistling or spitting. From this 
loss of tonicity the saliva is not retained on the affected side 
of the mouth, but runs out over the lip 5 to the great annoy- 
ance of the patient. 

The muscles of mastication, the masseter, temporal, and 
external and internal pterygoid, are supplied by the third 
branch of the fifth pair of nerves, and hence the ability to 
chew is not impaired. The buccinator, the function of 
which, in conjunction with the tongue, is to press the ali- 
mentary bolus against the jaws, and thus keep it submitted 
to their action, is supplied by the facial, and hence its office 
is not performed. The food consequently accumulates be- 
tween the jaws and the cheek, and it must be continually 
removed by the finger. 

The muscles which expand the face, as in the action of 
laughing or smiling, are supplied by the facial, and their 
paralysis destroys the normal equilibrium, and hence the 
face is drawn toward the sound side. This loss of antago- 
nism is most evident when the patient opens his mouth, and 
particularly when he laughs or smiles, for the paralyzed 
muscles, the zygomatici, and the risorius, are incapable of 
responding to the emotion, while those on the sound side con- 
tract vigorously. 

The paralysis of the occipito-frOntalis and of the corruga- 
tor supercilii prevents the raising of the eyebrows, or frown- 



724: DISEASES OF PERIPHERAL NERVES. 

ing, and obliterates all wrinkles from the brow. As Bom- 
berg remarks, there is no better cosmetic for elderly ladies 
than facial paralysis (" Firr alte frauen kein wirksameres 
cosmeticum existirt "). 

Among other symptoms, it is noticed that the ala nasi is 
depressed, and does not expand as air is drawn in through 
the nostril, and that the articulation, especially of words 
containing labials, is very indistinct. 

The expression of one side of the face is therefore de- 
stroyed ; it is a complete blank, incapable of responding to 
any emotion, and unable to execute those motions which 
in the normal condition are performed by its muscles. 

Such are the obvious and superficial symptoms of an or- 
dinary attack of unilateral facial paralysis. For the full 
understanding of other important phenomena, a few words in 
relation to the anatomy and physiology of the nerve are 
necessary. 

The facial nerve takes its origin from the posterior bor- 
der of the pons Yarolii and the lateral tract of the medulla 
oblongata. Some of its fibres of origin may be traced to the 
floor of the fourth ventricle, and even to the lateral columns 
of the spiual cord. A knowledge of its course and connec- 
tions enables us to determine with a good deal of accuracy 
the seat of the lesion by which it is paralyzed, and thus we 
have an important element in making a prognosis. 

From its point of apparent origin the facial passes for- 
ward and outward, resting on the crus cerebelli, and leaves 
the cranial cavity by entering the internal auditory meatus 
with the auditory nerve. It next enters the aqueductus 
Fallopii, and, passing through its whole length, makes its 
exit from the skull by the stylo-mastoid foramen ; while in 
the aqueductus Fallopii it gives off three branches, the two 
superficial petrosal nerves, and the chorda tympani. The 
great superficial petrosal passes to Meckel's ganglion, and 
through this supplies the levator palati and the azygos 
uvulse muscles; the small superficial petrosal — regarded by 



PERIPHERAL PARALYSIS. 725 

some as a branch of the glossopharyngeal, though commu- 
nicating with the facial — runs to the otic ganglion which 
supplies the tensor-palati and tensor-tympani muscles, and 
also, according to Bernard, presides over the secretion of the 
parotid gland, through the auriculo-temporal nerve ; the 
chorda tympani goes to join the gustatory branch of the 
fifth, and is in part distributed with this to tie tongue, but 
another portion of its fibres enters the submaxillary ganglion 
which presides over the function of the submaxillary gland. 

With this brief resume of the anatomical and physiologi- 
cal points of the facial nerve, we are prepared to study 
other symptoms to which I have not as yet alluded ; for, in 
the account given, I have simply considered the phenomena 
of facial paralysis when the lesion is situated on the distal 
side of the stylo-mastoid foramen. But the nerve may be 
affected farther back, and, though in such a case we have the 
symptoms already described, there are others which vary 
according to the seat of the disease. 

Thus, if the morbid process is in action above the origin 
of the chorda tympani, but below that of the petrosal nerves, 
the patient will experience a diminution but not a complete 
abolition of the sense of taste upon the corresponding side 
of the tongue. This fact led to the supposition that the 
chorda tympani was a sensitive nerve, but the experiments 
of Bernard and others have clearly shown that it is an effer- 
ent nerve, conveying influence from the brain, not to it. One 
of its actions is to increase the flow of submaxillary saliva. 
In addition, it supplies the lingualis muscle, and probably 
erects the papillae of the tongue, and modifies the circulation 
of this organ. When, therefore, a lesion of the facial exists 
above the origin of the chorda tympani, the sense of 
taste on that side is lessened because the dryness of the 
mouth prevents the ready solution of the sapid substance. 
The difficulty is augmented through the non-erection of the 
papillae, and perhaps, also, by the change which has ensued 
in the circulation. This diminution of the sense of taste 



726 DISEASES OF PERIPHERAL NERVES. 

therefore shows that the lesion is seated on the central side 
of the origin of the chorda tympani nerve. 

Again, if the lesion be situated behind the gangliform 
enlargement, from which the petrosal nerves arise, but an- 
terior to the meatus internus, we have, of course, all the 
symptoms mentioned, and in addition those due to paralysis 
of the petrosal. One of them is the depression of the pala- 
tine arch on the affected side ; it hangs lower than the oppo- 
site one, and its edge is nearly straight instead of curved. 
This condition results from paralysis of the levator-palati 
muscle, which, as we have seen, is supplied by the great 
petrosal through Meckel's ganglion. One of the two little 
muscles of the uvula being powerless, the other draws the 
uvula into a bow shape, with the concavity toward the 
sound side. The uvula and the velum are also pulled 
en masse toward the sound side by the action of the tensor 
palati, the other being paralyzed through the implication 
of the small petrosal nerve. The connection of the small 
petrosal through the otic ganglion with the parotid gland 
causes a diminution of the secretion of this gland when the 
lesion of the facial is in the situation described. 

Acuteness of hearing on the paralyzed side is sometimes 
observed. This is accounted for by Landouzy, 1 on the ground 
of the paralysis of the tensor-tympani muscle, which, as we 
have seen, is supplied by the otic ganglion, but Brown-Se- 
quard attributes it to hyperesthesia of the acoustic nerve 
from vaso-motor spasm. 

This last category of symptoms, therefore, indicates the 
seat of the lesion to be at or behind the gangliform enlarge- 
ment. 

When the lesion is within the cranium, we have all the 
symptoms mentioned, but they are complicated with others 
indicative of derangements of other nerves, or of cerebral 

1 De 1' Alteration de l'oui'e dans la Paralysie faciale, Gazette Medicale, 
Paris, 1851. 



PERIPHERAL PARALYSIS. 727 

disease. These have already been considered under other 
heads. 

In the foregoing account of facial paralysis, the unilateral 
form, which is by far the most common, has alone been con- 
sidered, but both nerves may be paralyzed, producing what 
is called double facial paralysis, or facial diplegia. The con- 
dition has been well described, among others, by "Wachsmuth, 1 
and by Pierreson, 3 the latter of whom has collected twenty- 
eight cases as the basis of his memoir. Both sides may be 
paralyzed simultaneously, in which instance the disease is 
probably central, or one may follow the other. In either 
case, the face presents a complete want of expression, and 
the symptoms previously mentioned are duplicated in full. 
Two excellent representations of the affection are given in 
the report of a case by Mr. Wright. 3 Only one case has 
come under my observation. It was of long standing and 
incurable. I lost sight of the patient before I could have 
his photograph taken. 

Causes. — Cold is a prominent cause of facial paralysis. 
It is most apt to cause that form of the disease in which the 
lesion is external to the temporal bone. Exposure to intense 
cold, especially when the wind was blowing, has caused sev- 
eral cases in my experience. The patient has gone to bed 
feeling pretty well, and has awakened with one side of the 
face paralyzed. 

Eheumatic inflammation, occurring in the course of the 
nerve, may also induce facial paralysis, as may likewise 
tumors of the parotid gland, or other cause capable of making 
pressure on the nerve. I have seen several cases which had 
resulted from sleeping with the closed hand under the face ; 
and it may occur in new-born children, as the result of 

1 TJeber progressive Bulbar-Paralyse und die Diplegia facialis. Dorpat, 
1864. 

9 De la Diplegie faciale. Archives Gen. de Hedecine, Aout, 1867, p. 139. 

3 Notes of a Case of Double Facial Palsy, British Medical Journal, 1869, 
p. 184. 



728 DISEASES OF PERIPHERAL NERVES. 

pressure by the forceps. Wounds and injuries of other kinds 
may, of course, produce it. 

"Within the temporal bone, facial paralysis may result 
from tumors from periostitis, from caries of the petrous 
portion of the temporal bone, from disease of the middle ear, 
from haemorrhage into the aqueductus Fallopii, and from 
fractures of the temporal bone. 

Within the cranium it may be caused by disease of the 
pons -Varolii, or of the medulla oblongata, by atrophy of the 
nerve, by tumors, and as the consequence of injury. 

Diagnosis. — Facial paralysis is distinguished from glosso-* 
labio-laryngeal paralysis, by the facts that in the latter the 
symptoms affect only the lower part of the face, and that 
they are accompanied by paralysis of the tongue and of the 
muscles of deglutition. From the facial paralysis of hemi- 
plegia it is diagnosticated by the marked circumstance that, 
in the latter disorder, the patient can close the eye, while in 
the former it remains wide open. There are no other affec- 
tions with which facial paralysis can be confounded, if the 
slightest attention be given to its symptoms. 

^Prognosis. — The prognosis varies according to the 'seat 
and the cause of the lesion, and the duration of the paraly- 
sis. If this latter is due to cerebral or intra-cranial dif- 
ficulty, or to disease existing within the aqueductus Fallo- 
pii, the prospect of cure is remote. But, if the lesion exists 
outside of the skull, and is capable of removal, or if the pa- 
ralysis be the result of exposure to cold, or subjection to 
pressure, and if the electric contractility of the muscles be 
not destroyed, the case, under suitable treatment, will prob- 
ably terminate favorably. By electric contractility, I do 
not mean the ability to respond to the excitation of the in- 
duced current, for this is lost at an early period in the 
majority of cases, but to contract upon the application of 
as strong a primary current as can with safety be applied 
to the face. 

In deep-seated lesions, if a clinical history of syphilis 



PERIPHERAL PARALYSIS. 729 

can be made out, the prognosis becomes more favor- 
able. 

If the affection has lasted a long time, and if contractions 
of the paralyzed muscles from atrophy have taken place, the 
probability of recovery is very slight, even if there is some 
glimmering of electro-contractility. 

Morbid Anatomy and Pathology — When facial paralysis 
results from cold, it may be from consequent neuritis, or 
from inflammation excited in contiguous parts. In the 
latter case lymph is effused and pressure is exerted upon the 
nerve. Most of the other causes act by the pressure they 
make on the nerve, and, though, as in the case of sleeping 
with the fist under the face, the action may not be long 
continued, the consequence is very lasting. The effects of 
pressure upon the nerve are experienced when we sit too long 
in one position, so as to compress the sciatic nerve, or when 
persons go to sleep with one arm thrown over the back of 
the chair on which they are sitting. The axillary plexus 
is compressed, and paralysis, more or less complete, of the 
muscles supplied by it, is the result. Several such cases 
have come under my observation, and the resulting paraly- 
sis is generally most difficult to remove. 

Treatment. — The indications are : to remove the cause if 
possible ; to put the nerve under the best possible conditions 
for regaining its lost power ; and to preserve the organic 
integrity and irritability of the muscles till this can take 
place. \Yhen there is reason to suspect the existence of a 
syphilitic taint, and the growth of exostoses of syphilitic 
character in the aqueductus Fallopii, the iodide of potassium 
with the bichloride of mercury should be given, according 
to the formula on page 322. In two cases I succeeded in 
effecting a cure by this treatment, conjoined with electricity, 
when the latter by itself had produced no improvement. 

For the restoration of the nerve function, we can do 
little beyond securing healthy nutrition of the general sys- 
tem, by the use of proper hygiene and tonics. Among the 



730 DISEASES OF PERIPHERAL NERVES. 

latter, strychnia is especially useful. I have never found 
blisters or liniments to be of the slightest service. 

The third indication is to be met by passive exercise, 
such as can be produced by pinching and kneading the 
muscles, and, above all, by the persistent use of electricity. 
Without this latter agent facial paralysis cannot be cured. 

If the induced current will cause the muscles to contract, 
it should be employed. One pole is placed over the nerve 
at its exit, from the stylo-mastoid foramen, and the mus- 
cles of the paralyzed side are separately excited by the other. 
A seance should last about fifteen minutes, and should be 
repeated every alternate day, or every day in bad cases. 

If the induced current will not cause contractions, the 
primary interrupted current should be used for the purpose. 
Care should be taken not to employ a current of too great a 
degree of intensity, as serious consequences have resulted to 
the vision by neglect of this precaution. As a rule, fifteen 
Smee's cells will be sufficient ; but, if the current be passed 
through a column of water before it reaches the face, a 
larger number of cells may be used with safety. Means 
must be taken to interrupt the current, as contractions are 
only produced when the circuit is closed and opened. 
When the primary current has been employed for a few 
weeks, it will generally be found that the induced will 
cause the muscles to contract, in which case it should be 
substituted. 

The first muscle to recover power is usually the orbicu- 
laris palpebrarum, but several weeks, and sometimes months, 
are requisite to bring about a complete cure. 



Other peripheral paralyses, such as those occurring in 
the muscles of the eye and its appendages, the muscles of 
the larynx, the muscles supplied by the motor branch of 
the fifth, the deltoid, etc., are to be treated upon the same 
general principles as are applicable to facial paralysis, the 
causes and pathology being very similar. 



CHAPTEE II. 

PERIPHERAL SPASM. 

There are two affections which may be taken as the 
types of peripheral spasm in general : these are spasm of 
the facial muscles — the mimic or histrionic spasm of Eom- 
berg, the convulsive tic of the French — and torticollis, or 
the spasm in the muscles of the neck supplied by the spinal 
accessory nerve. 

FACIAL SPASM. 

The spasms in the disease under notice may be either 
clonic or tonic, the former being by far the more common. 
In the clonic form, the muscles of the face, or a portion of 
them, generally on one side, are suddenly and violently 
contracted, and as suddenly relaxed. Sometimes, the angle 
of the mouth is drawn back again, the upper lip, and the 
alse of the nose are elevated ; and again, the spasm affects 
the orbicularis palpebrarum. In a case now under my 
charge, occurring in a gentleman from Rahway, New Jersey, 
both orbicularis muscles are affected with clonic and tonic 
spasms, the eyes sometimes being closed for several minutes 
at a time. 

The spasms come on in paroxysms which are of variable 
duration. I have seen them last continuously for over an 
hour. Generally, they continue from a few seconds to one 
or two minutes, and are repeated at intervals of about the 
same time. They may generally be excited by emotional 
disturbance of any kind ; by muscular exertion, by a current 



732 DISEASES OF PEEIPHERAL NERVES. 

of wind, or other cause capable of exciting reflex actions. 
In the case above referred to, they are always induced by 
walking. They can be made to cease by pressure upon the 
facial nerve at various points, and they are generally arrested 
by powerful mental occupation and by sleep. 

In the tonic form of the affection the spasm persists, and 
causes more or less distortion of the face. It interferes with 
articulation, mastication, and especially with emotional ex- 
pression. 

The tendency is for either form to become habitual, and 
hence to be difficult of cure. 

Causes. — Cold is a common cause, as are also wounds and 
injuries, and carious teeth. I have seen two cases recently, 
from this last-named influence. 

The Diagnosis calls for no special consideration, and the 
Prognosis depends very much upon the duration. Generally, 
it is unfavorable. 

There are no facts bearing on the Morbid Anatomy, and 
the Pathology is to be explained by the principle of reflex 
excitation which, in this case, probably takes place through 
the intermediation of the fifth pair. The analogy with 
chorea is very great. 

Treatment. — Of thirteen cases that have been under my 
charge, fi.ve were cured. The means which I have found 
most useful are, daily hypodermic injections of a mixture in 
water of five drops of Fowler's solution, and the one-fiftieth of 
a grain of atropia, and the daily use of the constant primary 
current to the facial nerve and the convulsed muscles. 

In several cases I have obtained good results from per- 
manent pressure over the facial nerve. The gentleman pre- 
viously referred to has had, at my suggestion, a steel spring 
constructed which terminates in two pads, and which he 
wears over the head in such a way as to compress the facial 
nerves at their exit from the stylo-mastoid foramen. "While 
he wears it he has no spasms, but he is unable to endure the 
pressure longer than a couple of hours. 



PERIPHERAL SPASM. 733 

Division of the affected muscles has been practised with 
very moderate success. 

TORTICOLLIS. 

In this disease the spasms — which, as in the correspond- 
ing affection of the face, may be either clonic or tonic — 
occupy the sterno-cleido-mastoid, the trapezius, the rhom- 
boids, and the levator anguli scapulae, separately or collec- 
tively. The movements of the head in the clonic form 
depend upon the seat of the spasms, the action being in the 
direction of the tractile force of the affected muscles. Some- 
times the contractions are very rapid, and again they are 
slow and regular ; as in facial spasm, they are aggravated by 
emotional excitement or physical exertion. They cease 
during engrossing mental occupation, and during sleep. 
Occasionally both sides are affected. 

The reverse of facial spasm, the tonic form, is much the 
more common, and it is to it that the term torticollis is 
usually applied by surgical writers. The sterno-cleido-mas- 
toid is generally its exclusive seat. The contraction is often 
accompanied by pain. 

Causes. — The etiology is not essentially different from 
that of facial spasm. 

Diagnosis. — There is no difficulty about the diagnosis of 
the clonic variety. The tonic form is, however, liable to be 
confounded with a similar affection so far as appearances 
and consequences go, which is a veritable myositis, but which 
is not an affection of the nervous system. The transitory 
character of the latter affection and the severe pains are 
sufficient diagnostic marks. 

Prognosis, — The prospect of recovery from the clonic form 
is very remote. Of seven cases that I have had under my 
charge, two only were cured. 

Of the Morbid Anatomy, or of the Pathology, nothing is 
known. 

Treatment. — I have made use of every remedy, in the 



734: DISEASES OF PERIPHERAL NERVES. 

clonic form, which could in my opinion be of service. Iron, 
belladonna, arsenic, morphia, chloral, chloroform, ether, 
bromide of potassium, strychnia, zinc, and many other medi- 
cines, have all failed. In one case I administered morphia 
hypodermically in gradually-increasing doses, till at last two 
grains were given twice a day, but without any permanent 
effect. I have divided the muscles in four cases without 
benefit. In one of them I cut both sterno-cleido-mastoids, 
the left trapezius at its insertion into the occipital bone, the 
left levator-anguli scapulas, and finally, with the concurrence 
of my friend Prof. Markoe, the left complexus. But as soon 
as one muscle was cut another became affected, and, after 
the division of the complexus, the expectation of obtaining a 
cure by myotomy was given up. The patient, a lady, from 
the South, is still affected, though she appears to be getting 
better gradually. 

Electricity in any form has never cured a case in my 
hands, though I have employed it steadily, for weeks at a 
time, both as the primary and induced currents. 

In the two successful cases, many means were tried with- 
out success. In one, that of a young man from Newark, in 
addition to other means, I divided the right sterno-cleido- 
mastoid muscle twice, and it was afterward cut by my 
friend Prof. Say re. All the operations were unsuccessful, 
although, as in the other cases, an apparatus was worn to 
prevent the too rapid union of the muscle. This patient 
was finally cured with large doses of the' bromide of po- 
tassium. 

In the other case, that of a lady of this city, every means 
used failed, till I tried the oxide of zinc ; she began with 
doses of two grains three times a day, which were gradually 
increased. When she reached fifteen grains at a dose, the 
spasms ceased and did not return. 

For the tonic variety, myotomy is the proper remedy, and 
it is generally successful if a suitable apparatus be subse- 
quently worn. 



CHAPTEK III. 

PERIPHERAL ANAESTHESIA. 

Almost any part of the body may be deprived of sensa- 
tion from causes acting on the peripheral nerves. One of 
the most familiar examples of this fact is the anaesthesia pro- 
duced in the foot and leg by pressure on the sciatic nerve in 
the act of sitting too long in one position ; another is the loss 
of sensibility produced in the hand and arm by pressure on 
the ulnar nerve as it passes over the elbow. 

Anaesthesia originating from cerebral, spinal, and cere- 
brospinal causes, has already been considered, and the pres- 
ent remarks will be strictly limited to the anaesthesia of 
peripheral origin. 

ANESTHESIA OF CUTANEOUS NERVES. 

Symptoms. — The symptoms of anaesthesia from peripheral 
causes do not vary materially from those which result from 
central lesions. They consist of the various sensations of 
numbness, such as tingling, " pins and needles," a feeling as 
if ants are crawling over the skin, water trickling over it, 
and, in complete cases, of absolute abolition of sensibility. 
The conducting power of the nerve may be impaired in so 
much as only to cause a retardation of the velocity of 
excitations, and thus an impression made on the terminal 
extremities of a nerve is not felt for a much longer time 
than would normally be the case. Peripheral anaesthesia 
may be accompanied with disorders of nutrition from irregu- 
larity of blood-supply. One form of the affection, of which 
I have seen several examples, and which probably owes its 



736 DISEASES OF PERIPHERAL NERVES. 

complication to vaso-motor spasm, is characterized by un- 
natural whiteness and shrinking of the skin, usually in the 
hands. If an incision be made, little or no blood escapes. 
In a young lady from Savannah, who was under my charge 
a short time since, this condition existed to an extreme de- 
gree, but disappeared with the removal of the anaesthesia. 
Anaesthesia of peripheral origin in the cutaneous nerves is 
often accompanied by more or less loss of power. 

Causes. — Peripheral cutaneous anaesthesia may be pro- 
duced by a variety of causes. Among the chief are wounds 
and injuries of various kinds, whereby the nerve is divided or 
its conducting power impaired ; pressure such as that caused 
by tumors, tight clothing, or accidental influences ; rheuma- 
tism; exposure to intense cold ; the action of certain drugs, 
such as aconite locally applied ; and diseases of the nerves. 

Diagnosis. — The important point in the diagnosis of pe- 
ripheral anaesthesia is the .discrimination between it and 
the anaesthesia, due to central causes. The elements of the 
diagnosis have been dwelt upon at some length by Eomberg, 
and perhaps needlessly so, for there can scarcely be a case 
in which any difficulty in forming a correct opinion can 
arise except in those cases of anaesthesia in which the fifth 
pair is involved, and they will presently be more especially 
considered. As regards the cutaneous nerves, the existence 
of a peripheral cause, and the non-existence of evidences of 
cerebral or spinal derangement, will be sufficient indications 
of the nature of the affection. It could scarcely happen 
that anaesthesia, the result of central lesions, could exist 
without other marked symptoms being present, not con- 
nected with cases of peripheral origin. 

Prognosis. — This depends very much upon the cause, 
and the ability to remove it. In cases of simple division of 
a nerve, union may be effected after a time, and the func- 
tions restored, but if any considerable portion of the nerve 
has been destroyed, the case is hopeless. Even when the 
cause is removed, as may be accomplished for instance ir 



PERIPHERAL ANESTHESIA. 737 

cases due to pressure, a long period often elapses before 
complete restoration takes place. 

The Morbid Anatomy and Pathology call for no special 
remarks after what lias already been said. 

Treatment. — The most important therapeutic measure 
consists in the removal of the cause. Unless this can be 
effected, it is useless to attempt other treatment. If this 
can be accomplished, electricity is the most efficient agent 
to be employed toward restoring the irritability to the 
nerves. Sometimes the primary current is to be preferred, 
at others the induced. In the latter case the wire brush 
should be used as one of the electrodes, and the anaesthetic 
parts be stroked with it at each seance. 

ANAESTHESIA OF THE FIFTH PAIR. 

Symptoms. — These vary according to the seat of the 
lesion. If the ophthalmic branch alone be implicated, the 
anaesthesia is situated in the forehead, the upper eyelid, the 
conjunctiva, and the lining membrane of the nostril. Irri- 
tating substances, therefore, coming in contact with the eye 
or the pituitary membrane, are not felt. 

If the difficulty is limited to the superior maxillary branch, 
the skin of the upper part of the face and the teeth of the 
upper jaw are insensible. When the inferior maxillary branch 
is affected, the temporal region, the skin covering the upper 
and lower jaw, the under lip, the chin, the lining membrane 
of the mouth, the anterior third of the tongue, and the 
teeth of the lower jaw, lose their sensibility ; mastication 
becomes difficult, and the saliva flows from the mouth. In 
either of these cases the seat of the lesion must be anterior 
to the Gasserian ganglion. When all the branches of the 
fifth are involved, and, as a consequence, anaesthesia exists 
throughout the whole of one side of the face, it is very cer- 
tain that the ganglion is affected,- or that the main trunk 
of the nerve is itself the seat of the disease. Anaesthesia 
of the fifth nerve due to lesion of the Gasserian ganglion, 
47 



738 DISEASES OF PERIPHERAL NERVES. 

or of the main trunk, is very generally accompanied by 
disorders of nutrition and derangement of the senses of 
sight, smell, and taste. Fungoid growths on the gums and 
defective circulation in the face are common in such cases ; 
but ulceration of the cornea and congestion of the conjunc- 
tiva do not occur unless the lesion is situated in the Gas- 
serian ganglion, or anterior to it in the ophthalmic branch. 

The Causes of peripheral anaesthesia of the fifth pair are 
analogous to those which produce the corresponding affec- 
tion in the cutaneous nerves ; but the Diagnosis requires a few 
special remarks, and these may be stated in the form of 
Romberg's propositions : 

" a. The more the anaesthesia is confined to single fila- 
ments of the trigeminus, the more peripheral the seat of the 
cause will be found to be. 

" h. If the loss of sensation affects a portion of the facial 
surface, together with the corresponding facial cavity, the 
disease may be assumed to involve the sensory fibres of the 
fifth pair before they separate to be distributed to their re- 
spective destinations ; in other words, a main division must 
be affected before or after its passage through the cranium. 

" e. When the entire sensory tract of the fifth nerve has 
lost its power, and there are at the same time derangements 
of the nutritive functions in the affected parts, the Gasseri- 
an ganglion, or the nerve in its immediate vicinity, is the 
seat of the disease. 

" d. If the anaesthesia of the fifth nerve is complicated 
with disturbed functions of adjoining cerebral nerves it may 
be assumed that the cause is seated at the base of the brain." 

The Prognosis, the Morbid Anatomy, the Pathology, and 
the Treatment, call for no remarks additional to those made 
when peripheral cutaneous anaesthesia was under considera- 
tion, except that, as regards the treatment, if the primary 
current is employed, care should be taken that the tension 
be not too high, a point to which reference has already fre- 
quently been made. 



CHAPTEE IT. 

PERIPHERAL HYPERESTHESIA {NEURALGIA). 

Under this head I propose to consider the principal 
painful affections embraced under the term neuralgia. No 
designation in medical nomenclature has been more abused 
than this. Any pains, the origin of which cannot readily 
be ascertained, and many which are well known to depend 
upon central lesions, are called neuralgic. I propose, in the 
present remarks, to include under it those affections only 
which, so far as can be ascertained, are not due to disease 
either of the brain or spinal cord, but the seat of which is 
in the nerves themselves. Following the classification of 
Valleix, I shall consider — 

a. Neuralgia of the fifth pair. 

b. Cervico-occipital neuralgia. 

c. Cervico-brachial neuralgia. 

d. Dorso-intercostal neuralgia. 

e. Lumbo-abdominal neuralgia. 
f. Crural neuralgia. 

g. Sciatic neuralgia. 

NEURALGIA OF THE FIFTH PAIR OF NERVES. 

Symptoms. — Either division of the fifth pair of nerves 
may be the seat of the disease, or all may be simultaneously 
affected. 

1. Ophthalmic Division. — This branch of the fifth is dis- 
tributed to the side of the nose, the eyelids, the lachrymal 
gland, the globe of the eye, the conjunctiva, the forehead, 



740 DISEASES OF PERIPHERAL NERVES. 

and the scalp. The long root of the ciliary ganglion com- 
municates with the nerve, and anastomoses take place with 
the superior maxillary branch. 

Valleix has shown that there are particular spots in 
which neuralgic pains are always more severe than in others, 
and that these are the points where the nerve either passes 
through a foramen in a bone, or penetrates a fascia. In the 
ophthalmic nerve several of these points are to be found. 
The most prominent is in the nerve as it passes out of the 
supra-orbital foramen to ramify on the forehead and scalp ; 
another is seated in the upper eyelid ; another in the long 
nasal branch as it passes to the skin through the line of 
union of the nasal bone with the cartilage; another is 
located in the eyeball, and another at the inner angle of the 
orbit. Besides these which are peculiar to the ophthalmic 
branch, there is another situated near the parietal emi- 
nence, and which corresponds to the inosculation of various 
branches. 

The most common form of neuralgia affecting the oph- 
thalmic division of the fifth nerve is hemicrania. The 
occurrence of the paroxysms is marked by a tendency to 
periodicity. The pain is exceedingly sharp and lancinating, 
and occupies the frontal, temporal, or parietal regions, being 
especially intense at the point corresponding to the supra- 
orbital foramen, or at that situated near the parietal emi- 
nence. It frequently happens that this latter spot is the 
only part affected. The paroxysm usually comes on in the 
morning, and rarely lasts longer than twenty-four hours ; 
frequently it disappears at nightfall. The pain is greatly 
aggravated by mental or physical exertion, by loud noises 
or bright lights. It is often complicated with nausea and 
vomiting, in which case it constitutes what is known as 
sick-headache. In other cases the pain is mainly confined 
to the eyeball and the accessory parts. There is then lach- 
rymation, from the fact that the lachrymal gland is sup- 
plied from the ophthalmic division, and there may be visual 



PERIPHERAL HYPERESTHESIA (NEURALGIA) 741 

troubles from the relation which the nerve bears to the 
ciliary ganglion. 

This form may also be distinctly periodical in its occur- 
rence, and it rarely lasts longer at one time than twenty- 
four hours. 

2. Superior Maxillary Division. — The distribution of 
this branch is to the teeth of the upper jaw, the lower eye- 
lid, the side of the nose, the upper lip, to the lining mem- 
brane of the nose and mouth, and to the temple and cheek. 
It inosculates freely with the ophthalmic division, and is in 
intimate relations with the spheno-palatine ganglion. 

The painful points of Yalleix for this nerve are, in the 
infra-orbital nerve as it emerges from the infra-orbital fora- 
men to be distributed to the lower eyelid, the side of the 
nose, and the upper lip ; over the most prominent part of 
the malar bone, where the nerve is very superficial ; an un- 
certain point on the gums of the upper jaw ; a similar point 
on the upper lip, and another on the palate. Neuralgia of 
this division occurs in paroxysms, and may, like that of the 
ophthalmic, be periodical in its attacks. 

3. Inferior Maxillary Division. — This nerve is distrib- 
uted to the cheek, the tongue, the lower jaw and teeth, and 
to the sub-maxillary gland. It is also in connection with 
the otic and sub-maxillary ganglia. 

Its painful points are a spot on the auriculo-temporal 
branch, just in front of the ear ; another on the inferior 
dental nerve, where it emerges from the inferior dental 
canal, through the mental foramen. 

It is generally the case that facial neuralgia is limited to 
one side, but both are sometimes affected. It may also be 
confined to very restricted boundaries, the extreme terminal 
branches alone being involved. 

Causes. — According to my experience, facial neuralgia is 
rarely met with in young persons, but is more common 
during adult life. It is certainly more apt to attack females 
than males, and is often transmitted by hereditary influence. 



742 DISEASES OF PERIPHERAL NERVES. 

The most common exciting cause is, in this country, 
malaria, and this is especially the case with the affection in 
the ophthalmic division, as manifested in hemicrania and 
supra-orbital neuralgia. This latter is often popularly 
known as " brow-ague." 

Among other causes are to be mentioned mental excite- 
ment, anxiety, intense intellectual exertion, exposure to cold 
and damp, the loss of blood, as in the case of women after 
child-birth, or from menorrhagia, prolonged lactation, and 
the changes due to the cessation of the menses. 

Another very common cause is syphilis, and there is 
reason to think that the gouty diathesis may also excite it. 

But, as Anstie 1 remarks, it is after the powers of life 
begin to decline that the most formidable varieties of facial 
neuralgia are encountered. • Those forms which are attend- 
ed with muscular spasm, constituting the " tic douloureux " 
of the French, and another still more violent which Trous- 
seau has designated " tic epileptiform," are almost peculiar 
to advanced life. The pain in these affections is atrocious, 
and is excited by the least muscular action in the face, by a 
touch, however light, or even by a breath of air. They are 
often accompanied by an hereditary tendency to insanity, 
and they eventually wear away the life of the miserable 
sufferer. 

Facial neuralgia may also result from tumors compress- 
ing the nerves, from thickening of the bones, or of the 
peiosteum, causing narrowing of the foramina through 
which they pass, and from interstitial organic changes 
taking place in the nerve-trunks. 

The Diagnosis requires no special remarks, and the 
Prognosis depends upon the cause, and the ability to re- 
move it. In general terms it may be stated that the mala- 
rial and syphilitic forms are usually readily cured, while 
others are seldom thoroughly relieved. The intense varie- 
ties, coming on for the first time late in life, are absolutely 

1 Article Neuralgia, in Reynolds's System of Medicine, vol. ii., p. 726. 



PERIPHERAL HYPERESTHESIA (NEURALGIA). 743 

incurable, and are very seldom capable of even being miti- 
gated. 

CERVICO-OCCTPITAL NEURALGIA. 

In this affection the pain is situated in the sensory 
branches of the first four cervical nerves, though the great 
occipital which arises from the second cervical is mainly 
the one affected. These nerves are distributed to the occi- 
pital and posterior parietal regions, as well as to the neck 
and lower part of the cheek. The painful points are those 
at which the nerves become most superficial. 

The pain in cervico-occipital neuralgia, though severe, 
is not in general so intense as that of the facial variety. 
There is a tendency in the affection to extend so as to in- 
volve the inferior maxillary nerve, and, when the disease 
has lasted some time, a paroxysm rarely occurs without this 
nerve being implicated. After the acute stage of a paroxysm 
has passed off, there remains a dull, heavy pain, which con- 
tinues several days, and which is increased by the pressure 
of the clothing, by mental exertion, or by moving the head. 

The Causes are similar in general character to those of 
facial neuralgia, though cold is probably a still more power- 
ful factor in the etiology. 

The Diagnosis and Prognosis call for no special remarks. 

CERVICO-BRACHIAL NEURALGIA. 

In this form the brachial plexus, the nerves which go to 
form it — the five lower cervical and first dorsal— and those 
which arise from it, are the seat of the affection. The pain 
may therefore be felt in the subclavicular region, along the 
whole length of the upper extremity, or in the situation of 
the mammary gland. The exact seat varies of course with 
the particular nerve affected. It is often accompanied by 
various sensations of numbness, and interferes more or less 
with the movements of the limb. The principal painful 
points are the axillary in the arm-pit, and corresponding to 



744 DISEASES OF PERIPHERAL NERVES. 

the brachial plexus, the scapular near the inferior angle of 
the scapula, the acromial in the angle between this process 
and the clavicle, the median cephalic in the bend of the 
elbow, the ulnar corresponding to the most superficial por- 
tion of the ulnar nerve at the back of the elbow-joint, and 
the radial at the point where the radial nerve becomes su- 
perficial at the lower part of the forearm. 

Among the Causes of cervico-brachial neuralgia, excessive 
muscular exertion and injuries are preeminent. It is not 
so frequently the result of malaria as the corresponding 
affection of the facial nerve. 

There is nothing special to be said relative to the 
Diagnosis and Prognosis. 

DOKSO-LNTERCOSTAL NEURALGIA. 

In this affection the dorsal and intercostal nerves are 
the seat of the pain. In the first case the disease is often 
regarded as rheumatic or muscular, and has received the 
popular name of lumbago ; in the latter it is often known 
as pleurodynia. Whether in the dorsal or intercostal form, 
the pain does not often occur in well-marked paroxysms, 
but is more or less continuous in character, and is much 
increased by muscular exertion. In the dorsal form, the 
mere act of straightening the back causes great suffering, 
and in the intercostal respiration is exceedingly painful. 

The painful points are very numerous, and in general 
correspond to the situations where the nerves become most 
superficial. 

The association of intercostal neuralgia with herpes zoster 
of unilateral form is an interesting fact, and one which has 
led to the recognition of other skin-diseases as being essen- 
tially nervous affections. . 

The Causes of dorso-intercostal neuralgia are cold, ex- 
haustion, and, in women, the depression of vital power, 
due to profuse menstruation or prolonged lactation. Anse- 



PERIPHERAL HYPERESTHESIA (NEURALGIA). 745 

mia, both in males and females, is also a common cause, 
however produced. 

The Diagnosis of the dorsal form is not a matter of dif- 
ficulty ; the intercostal has, however, often been mistaken for 
pleurisy. The Prognosis is more favorable than in the other 
neuralgias described. 

Lumbo-abdominal and crural neuralgias are not very 
common. The latter is seldom a primary affection. 

SCIATIC NEURALGIA. 

This form is characterized by the occurrence of pain in 
the course of the sciatic nerve and its branches, mainly in 
those distributed to the skin. It may be restricted to the 
gluteal region and upper part of the thigh, or may extend 
to the sole of the foot or toes. The principal painful points 
are those which correspond to the sacral foramina, where 
the large and small sciatic nerves emerge from the pelvis ; 
a series corresponding to the emergence of cutaneous branch- 
es through the fascia, a fibular point at the head of the fibula, 
an external malleolar, and an internal malleolar. 

Sciatica generally begins as a dull, heavy ache, which 
gradually becomes more and more intense, and which, like 
all the other forms of neuralgia, is aggravated by muscular 
exertion. It is subject to exacerbations of violence, during 
which the least agitation of the body still further increases 
the intensity of the suffering. Sometimes the pain darts 
through the nerves like electric shocks, while at others it re- 
tains its original situation. It is often accompanied by mus- 
cular contractions. Anaesthesia is generally present in the 
parts which are or have been the seats of the pain, and can 
readily be detected with the aesthesiometer. 

The affection generally lasts two or three months, and is 
liable to recur. 

Causes. — The etiology of sciatica is not materially dif- 
freent from that of other neuralgias, except so far as it is 



746 DISEASES OF PERIPHERAL NERVES. 

modified by local circumstances. Among these latter, are 
enlargement of the prostate gland, by which pressure is 
exerted on the nerve, various tumors of the abdominal 
organs, the pressure of the foetal head in child-birth, accu- 
mulations of faeces in the large intestine, etc. It is also 
occasionally induced by the pressure on the nerve which 
results from sitting long on a hard chair. Several cases of 
this kind have come under my observation. 

The Diagnosis is not a matter of any difficulty, though I 
have many times seen cases mistaken for diseases of the 
spinal cord, and vice versa. The Prognosis depends greatly 
on the ability to remove the cause. 

Morbid Anatomy and Pathology. — The remarks which might 
be made under this head have already been expressed to 
some extent in the foregoing pages, and there is not much 
more that could be said without entering the domain of pure 
speculation. I may, however, state my opinion that neural- 
gia, not directly the result of some physical cause interfering 
with the integrity of the nerve in which it is situated, is 
almost invariably induced by a depressed state of the system. 
Its existence in such cases is evidence, therefore, of deficient 
physical stamina, and of the fact that the nervous system is 
not duly nourished. The remote factor may be malaria, 
syphilis, rheumatism, gout, or some other cause capable of 
lowering the vitality of the organism, and, as a consequence, 
that of the nerves. It is of course of the utmost importance, 
with reference to the treatment, to ascertain whether there 
is, or is not, any such constitutional taint, but, whatever the 
result of our inquiries in this direction, that system of thera- 
peutics is best which, in addition to physical measures, em- 
braces restorative means. 

Treatment. — The measures which it is proper to employ 
in neuralgia may be divided into two categories, the consti- 
tutional and the local. 

Among the constitutional remedies must be included 



PERIPHERAL HYPERESTHESIA (NEURALGIA). 74.7 

those which are for the correction of any taint which may- 
be present. If there is reason to suspect the existence of 
syphilis, iodide of potassium is an indispensable remedy, and 
should be given in large doses. If malaria can be ascer- 
tained to have exerted an influence, quinine must be admin- 
istered ; and, indeed, it is safe to act upon the theory that 
this has been the cause, unless some other can be clearly 
made out. It must be recollected that malaria may give 
rise to neuralgia, especially in the facial nerve, without there 
having been any other manifestation of its toxic effect ; and 
that the affection is often cured by large doses of quinine, 
when the patient has not apparently been subjected to the 
malarious influence. Should there be no relief after three 
or four ten-grain doses of quinine, it should still not be de- 
cided that the disease is not of malarious origin, but arsenic 
should be administered. I have seen many cases of supra- 
orbital neuralgia, undoubtedly the result of miasmatic poi- 
soning, effectually cured by arsenic, when quinine had failed. 
From my own experience, I am very well convinced that it 
acts much more efficaciously when administered by hypoder- 
mic injection than by the stomach. Four drops of Fowler's 
solution, diluted with an equal quantity of water, should be 
given twice a day, and the quantity should be gradually 
increased to eight or ten drops at a dose. 

If a gouty diathesis is present, colchicum should be used ; 
and, if rheumatism be clearly made out, the blood should at 
once be rendered alkaline by liquor potassse. 

Whether any specific difficulty be discovered or not, gen- 
eral tonics are always indicated ; among them cod-liver oil 
occupies the front rank, and iron is not far behind it in 
value ; strychnia is also very generally useful. Among con- 
stitutional remedies, ergot has proved of very decided benefit 
in my hands, and this especially in sciatica. It should be 
given in large doses, a drachm or more of the tincture three 
times a day. 

A full and nutritious diet is of great value in the treat- 



748 DISEASES OF PERIPHERAL NERVES. 

ment of neuralgia, as are likewise sunlight, and pure and 
fresh air. 

In addition to these purely constitutional measures, 
there are others which, though administered to act upon 
the system at large, are given for the purpose of arrest- 
ing a paroxysm, or deadening sensibility, so as to prevent 
the pain being felt. The medicines embraced in this cate- 
gory are included among the stimulants, narcotics, and 
anaesthetics. Opium and its various preparations are preemi- 
nent as palliatives of the neuralgic paroxysm, and morphia 
stands first among them. It is most efficaciously adminis- 
tered hypodermically, in doses varying from one-eighth grain 
to half a grain, or even more in extreme cases. Great care 
should be exercised in its use, and the smaller quantity men- 
tioned should not be exceeded except by regular gradations. 
It is immaterial in what part of the body the injection is 
made, so far as its influence over the pain is concerned. 

Among other medicines of this class are belladonna, or 
its alkaloid atropia, Indian hemp, aconite, bromide of potas- 
sium, hydrate of chloral, hyoscyamus, conium, and some 
others of minor importance. 

Of very great value are chloroform and ether, adminis- 
tered by inhalation, and the various forms of alcoholic 
liquors. 

The chief local means of treatment in neuralgia are 
counter-irritation — preferably in the form of repeated blis- 
ters, which should be applied over the course of the painful 
nerves, and which are especially valuable in sciatica — and 
the local application of tincture of aconite, and of veratria in 
the form of an ointment, or an alcoholic or ethereal solution. 

But, above all local means, not only for relieving the pain 
of any particular paroxysm, but also for effecting a perma- 
nent cure, electricity stands first. I have employed it in 
every possible form, and am satisfied that the primary gal- 
vanic current is the preferable agent. Indeed, I very much 
doubt if the induced current, unless in a few cases, when 



PERIPHERAL HYPERESTHESIA (NEURALGIA). 749 

the wire-brush has been employed, has ever, in my experi- 
ence, accomplished any very decided benefit. In the 
employment of the primary current, the positive pole 
should be applied over the seat of the pain, and not more 
than fifteen or twenty Smee's cells should be used. The ap- 
plication should be continuous for at least half an hour, and 
should be repeated every day for several weeks, and in ex- 
treme cases longer. I have cured a number of severe cases 
of nearly every kind of neuralgia by the aid of electricity 
when other means had entirely failed. I rarely, however, 
employ it without at the same time insisting on such con- 
stitutional treatment as the case seems to require. 

I have several times used acupuDcture with success, and 
have likewise employed electro-puncture with decided bene- 
fit in ten cases of sciatica. In either operation the needles 
should be introduced at the most painful parts, and, when 
galvanism is also used, the current should be passed continu- 
ously through the needles. In a notable case of sciatica 
which I saw in consultation with my friend Dr. John Gal- 
laher, of this city, a severe attack of sciatica was at once cut 
short by electro-puncture. Two or three cells will afford a 
current of sufficient tension. 

As to surgical operations on the affected nerves, either of 
section or excision of a portion of their continuity, the suc- 
cess which has hitherto followed them has not been such as, 
in my opinion, to warrant their repetition. 



IifDEX. 



Abscess, chronic cerebral, 254. 
Active cerebral congestion, 33. 

symptoms, 34. 

apoplectic form of, 37. 

epileptic form of, 39. 

maniacal form of, 

first stage of, 34. 

second stage of, 37. 

third stage of, 41. 
Acute cerebral meningitis, 219. 
Acute myelitis, 456. 

symptoms, 456. 

causes, 459. 

diagnosis, 459. 

prognosis, 460. 

morbid anatomy, 460. 

pathology, 460. 

treatment, 460. 
Acute spinal meningitis, 444. 
Affective insanity, 336. 
Anaemia, cerebral, 61. 
Anaemia of antero-lateral columns of 
cord, 430. 

symptoms, 432. 

causes, 432. 

diagnosis, 433. 

prognosis, 433. 

morbid anatomy, 434. 

pathology, 434. 

treatment, 437. 
Anaemia, spinal, 396. 

of posterior columns of spinal cord, 
397. 
Anaesthesia of cutaneous nerves, 735. 

symptoms, 735. 

causes, 736. 

diagnosis, 736. 

prognosis, 736. 
Anaesthesia of the fifth pair, 737. 

symptoms, 737. 

causes, 738. 

diagnosis, 738. 

prognosis, 738. 

morbid anatomy, 738. 

pathology, 738. 

treatment, 738. 
Anaesthesia, peripheral, 735. 



Antero-lateral columns of cord, anae- 
mia of, 430. 

sclerosis of, 471. 
Aphasia, 166. 
Athetosis, 654. 

cases of, 654. 

description of, 654. 
Atrophy and disappearance of motor 
nerve-cells, 677. 

of motor and trophic nerve-cells,689. 

of trophic nerve-cells, 663. 

Brain, tumors of, 301. 

Catalepsy, 590. 

symptoms, 590. 

causes, 594. 

diagnosis, 594. 

prognosis, 595. 

morbid anatomy, 595. 

pathology, 595. 

treatment, 596. 
Cerebral abscess, chronic, 254. 
Cerebral anaemia, 61. 

symptoms, 61. 

causes, 64. 

diagnosis, 6Q. 

prognosis, 67. 

morbid anatomy, 67. 

pathology, 67. 

treatment, 69. 
Cerebral arteries 2 obliteration of, 119. 
Cerebral congestion, 33. 

causes, 43. 

diagnosis, 46. 

prognosis, 49. 

morbid anatomy, 50. 

pathology, 52. 

treatment, 54. 
Cerebral haemorrhage, 74. 

symptoms, 74. 

causes, 85. 

diagnosis, 90. 

prognosis, 95. 

morbid anatomy, 97. 

pathology, 99. 

treatment, 106. 



INDEX. 



751 



Cerebral meningitis, acute, 219. 

symptoms, 219. 

causes, 224. 

diagnosis, 225. 

prognosis, 225. 

morbid anatomy, 226. 

pathology, 227. 

treatment, 228. 
Cerebral meningitis, chronic, 231. 

tubercular, 234. 
Cerebral rheumatism, 223. 
Cerebral sclerosis, diffused, 260. 

multiple, 278.' 
Cerebral softening, 137. 

symptoms, 137. 

causes, 145. 

diagnosis, 147. 

prognosis, 148. 

morbid anatomy, 149. 

pathology, 151." 

treatment, 157. 
Cerebritis, 246. 
Cerebro-spinal diseases, 545. 
Cerebro - spinal . sclerosis, multiple, 

637. 
Cervico-brachial neuralgia, 743. 

causes, 744. 

diagnosis, 744. 

prognosis, 744. 
Cervico-occipital neuralgia, 743. 

causes, 743. 
■ diagnosis, 743. 

prognosis, 743. 
Chronic cerebral abscess, 254. 
Chronic cerebral meningitis, 231. 

symptoms, 231. 

causes, 232. 

diagnosis, 232. 

prognosis, 232. 

morbid anatomy, 232. 

pathology, 232. 

treatment, 232. 
Chronic spinal meningitis, 445. 
Chorea, 600. 

symptoms, 601. 

causes, 609. 

diagnosis, 610. 

prognosis, 611. 

morbid anatomy, 612. 

pathology, 612. 

treatment, 615. 
Classification of insanity, 335. 
Congestion, cerebral, 33. 

spinal, 385. 
Cretinism, 338. 
Crural neuralgia, 745. 
Cutaneous nerves, anaesthesia of, 735. 

Definition of insanity, 332. 
Degeneration, secondary, of spinal 

cord, 523. 
Delirium, 343. 
Delusion, 341. 
Dementia, 336, 338, 373, 374. 



Dementia, organic, 337. 

senile, 337. 
Diffused cerebral sclerosis, 260. 

symptoms, 260. 

causes, 272. 

diagnosis, 273. 

prognosis, 273. 

morbid anatomy, 274. 

pathology, 275. 

treatment, 275. 
Diseases of nerve-cells, 663. 

of peripheral nerves, 721. 

of the spinal cord, 385. 
Dura mater, hematoma of, 116. 

Eccentricity, 331. 
Ecstasy, 597. 

symptoms, 597. 

causes, 598. 

diagnosis, 598. 

prognosis, 598. 

morbid anatomy, 598. 

pathology, 598. 

treatment, 598. 
Embolism, 127. 

symptoms, 127. 

causes, 131. 

diagnosis, 132. 

prognosis, 134. 

morbid anatomy, 134. 

pathology, 134. 

treatment, 136. 
Emotions, 328. 
Emotional insanity, 338, 351. 
Encephalitis, 246. 
Epilepsy, 560. 

symptoms, 560. 

paroxysm, varieties of, 563. 

causes, 572. 

diagnosis, 575. 

prognosis, 576. 

morbid anatomy, 577. 

pathology, 578. 

treatment, 582. 
Epileptic insanity, 337. 

Facial neuralgia, 739. 
Facial paralysis, 722. 

symptoms, 722. 

causes, 727. 

diagnosis, 728. 

prognosis, 728. 

morbid anatomy, 729. 

pathology, 729. 

treatment, 729. 
Facial spasm, 731. 

symptoms, 731. 

causes, 732. 

diagnosis, 732. 

prognosis, 732. 

morbid anatomy, 732. 

pathology, 732. 

treatment, 732. 



752 



INDEX. 



Fifth pair, anaesthesia of, 737. 

hyperesthesia of, 739. 

neuralgia of, 739. 
Functional derangements of motor 



General paralysis, 338 2 366. 
General principles of insanity, 324. 
Gliomata, 320. 
Glosso-labio-laryngeal paralysis, 677. 

symptoms, 678. 

causes, 684. 

diagnosis, 685. 

prognosis, 686. 

morbid anatomy, 686. 

pathology, 687. 

treatment, 688. 

Haemorrhage, meningeal, 115. 
Haemorrhage, spinal meningeal, 440. 
Haemorhage, spinal, 440. 

symptoms, 440. 

causes, 441. 

diagnosis, 441. 

prognosis, 441. 

morbid anatomy, 442. 

pathology, 442. 

treatment, 442. 
Haematoma of the dura mater, 116. 

causes, 117. 

prognosis, 117. 

diagnosis, 117. 

morbid anatomy, 118. 

pathology, 118. 

treatment, 118. 
Hallucination, 340. 
Hydrophobia, 545. 

symptoms, 545. 

causes, 551. 

diagnosis, 553. 

prognosis, 554. 

morbid anatomy, 556. 

pathology, 556. 

treatment, 557. 
Hyperaesthesia peripheral, 739. 
Hypertrophy of muscular connective 
tissue, 699. 

symptoms, 700. 

causes, 701. 

diagnosis, 703. 

prognosis, 703. 

morbid anatomy, 703. 

pathology, 704. 

treatment, 705. 
Hysteria, 619. 

symptoms, 619. 

causes, 629. 

diagnosis, 631. 

morbid anatomy, 632. 

pathology, 632. 

treatment, 634. 

Idiocy, 336, 338, 373. 



Illusion. 339. 
Imbecility, 336. 
Incoherence, 342. 
Infantile paralysis, 689. 
Inhibitory paralysis, 431. 
Insanity, 324. 

classification of, 335. 

causes, 376. 

diagnosis, 377. 

prognosis, 377. 

morbid anatomy, 378. 

pathology, 378. 

treatment, 380. 

definition of, 332. 

affective, 336. 

emotional, 338, 351. 

epileptic, 337. 

intellectual, 338, 345. 

perceptional, 338, 343. 

paralytic, 337. 

simple, 337. 

volitional, 338, 357. 
Intellect, 328. 

Lead paralysis, 715. 
symptoms, 715. 
causes, 716. 

diagnosis, 717. 

prognosis, 717. 

morbid anatomy, 718. 

pathology, 718. 

treatment, 719. 
Locomotor ataxia, 484. 
Lumbo-abdominal neuralgia, 745. 

Mania, 336, 338, 358. 
Melancholia, 336. 
Meningealhaemorrhage, 114. 

causes, 115. 

prognosis, 116. 

diagnosis, 116. 

morbid anatomy, 116. 

pathology, 116. 

treatment, 116. 
Meningitis, cerebral, chronic, 231. 

cerebral, acute, 219. 

cerebral, tubercular, 234. 

spinal, 444. 

senile, 223. 
Monomania, 336. 

Motor nerve-cells, atrophy and disap- 
pearance of, 677. 
Motor nerve-cells, functional derange- 
ments of, 706. 
Motor and trophic nerve-cells, atrophy 

and disappearance of, 689. 
Multiple cerebral sclerosis, 278. 

symptoms, 269. 

causes, 288. 

diagnosis, 289. 

prognosis, 290. 

morbid anatomy, 290. 

pathology, 291. 



INDEX. 



753 



Multiple cerebro-spinal sclerosis, 637. 

symptoms, 637. 

causes, 651. 

diagnosis, 651. 

prognosis, 652. 

morbid anatomy, 652. 

pathology, 652. 

treatment, 652. 
Muscular connective tissue, hypertro- 
phy of, 699. 
Myelitis, acute, 456. 

Nerve-cells, diseases of, 663. 
Nerve-cells, motor, functional derange- 
ments of, 706. 
Nerves, cutaneous, anaesthesia of, 735. 
Neuralgia, 739. 

varieties of, 739. 

causes,- 344. 

diagnosis, 745. 

prognosis, 745. 

morbid anatomy, 746. 

pathology, 746. 

treatment, 746. 
Neuralgia of fifth pair of nerves, 739. 

symptoms, 739. 

causes, 741. 

diagnosis, 742. 

prognosis, 742. 
Neuralgia, cervico-brachial, 743. 

cervico-occipital, 743, 

crural, 745. 

dorso-intercostal, 744. 

luinbo-abdominal. 745. 

sciatic, 745. 

Obliteration of cerebral arteries, 119. 
Organic dementia, 337. 
Organic infantile paralysis, 689. 

symptoms, 689. 

causes, 691. 

diagnosis, 691. 

prognosis, 691. 

morbid anatomy, 692. 

pathology, 695. 

treatment, 696. 

Paralysis agitans, 706. 

symptoms, 707. 

causes, 708. 

diagnosis, 708. 

prognosis, 708. 

morbid anatomy, 709. 

pathology, 709. 

treatment, 710. 
Paralysis, general, 338, 366. 

infantile, 689. 

inhibitory, 431. 

reflex, 431. 

facial, 722. 

lead, 715. 

peripheral, 722. 
Paralytic insanity, 337 
Partial cerebral anaemia, 119. 
48 



Passive cerebral congestion, 41. 

symptoms, 41. 

first stage of, 41. 

apoplectic form of, 42. 

second stage of, 42. 

epileptic form of. 42. 

maniacal form of, 42. 
Pathetic insanity, 336. 
Peripheral anaesthesia, 735. 

hyperesthesia, 739. 

nerves, diseases of, 721. 

paralysis, 722. 

spasm, 731. 
Perception, 327. 
Perceptional insanity, 338, 343. 
Posterior columns of spinal cord, anae- 
mia of, 397. 
Posterior columns of spinal cord, scle- 
rosis of, 484. 
Progressive muscular atrophy, 663. 

symptoms, 664. 

causes, 668. 

diagnosis, 670. 

prognosis, 670. 

morbid anatomy, 670. 

pathology, 674. 

treatment, 676. 

Keflex paralysis, 431. 

Sciatic neuralgia, 745. 

causes, 745. 

diagnosis, 746. 

prognosis, 746. 
Sclerosis, multiple, cerebral, 278. 
Sclerosis, cerebro-spinal, 637. 
Sclerosis, diffused cerebral, 260. 
Sclerosis of antero-lateral columns of 
spinal cord, 471. 

symptoms, 471. 

causes, 476. 

diagnosis, 477. 

prognosis, 477. 

morbid anatomy, 477. 

pathology, 477. 

treatment, 482. 
Sclerosis of posterior columns of spinal 
cord, 484. 

symptoms, 484. 

causes, 496. 

diagnosis, 496. 

prognosis, 498. 

morbid anatomy, 498. 

pathology, 499. 

treatment, 513. 
Secondary degeneration of spinal cord, 
523. 

symptoms, 524. 

causes, 526. 

diagnosis, 526. 

prognosis, 526. 

morbid anatomy, 527. 

pathology, 527. 

treatment, 527. 



754 



INDEX. 



Senile dementia, 337. 
Senile meningitis, 223. 
Simple insanity, 337. 
Softening, cerebral, 137. 

spinal, 463. 
Spasm, peripheral, 731. 

facial, 731. 

writer's, 710. 
Spinal cord, anaemia of posterior col- 
umns of, 397. 

sclerosis of antero-lateral columns 
of, 471. 

sclerosis of posterior columns of, 484. 

secondary degeneration of, 523. 

tumors of, 517. 
Spinal anaemia ; 396. 
Spinal congestion, 385. 

symptoms, 385. 

causes, 388. 



prognosis, 390. 

morbid anatomy, 391. 

pathology, 391. 

treatment, 392. 
Spinal haemorrhage, 440. 
Spinal meningeal haemorrhage, 440. 
Spinal irritation, 397. 

symptoms, 408. 

morbid anatomy, 416. 

Sathology, 416. 
iagnosis, 419. 

treatment, 422. 
Spinal meningitis, 444. 

symptoms, 444. 

causes, 446. 

diagnosis, 447. 

morbid anatomy, 448. 

pathology, 448. 

treatment, 448. 
Spinal softening, 463. 

symptoms, 463. 

causes, 467. 

diagnosis, 467. 

prognosis, 468. 

morbid anatomy, 468. 

pathology, 468. 

treatment, 469. 
Suppurative encephalitis, 246. 

symptoms, 246. 

causes, 251. 

diagnosis, 251. 

prognosis, 253. 

morbid anatomy, 253. 

pathology, 253. 

treatment, 258. 

Tetanus, 529. 

symptoms, 529. 
causes, 533. 
diagnosis, 534. 
prognosis, 536. 
morbid anatomy, 537. 
pathology, 537. 
treatment, 539. 



Thrombosis, 119. 

symptoms, 119. 

causes, 121. 

prognosis, 122. 

diagnosis, 122. 

morbid anatomy, 123. 

pathology, 123. 

treatment, 126. 
Trophic nerve-cells, atrophy and dis- 
appearance of, 663. 
Tubercular cerebral meningitis, 234. 

symptoms, 234. 

causes, 240. 

diagnosis, 241. 

prognosis, 242. 

morbid anatomy, 242. 

pathology, 242. 

treatment, 244. 
Torticollis, 733. 

symptoms, 733. t 

causes, 733. 

diagnosis, 733. 

prognosis, 733. 

morbid anatomy, 733. 

pathology, 733. 

treatment, 733. 
Tumors of the brain, 301. 

symptoms, 301. 

causes, 311. 

vascular, 311, 315. 

parasitic, 312, 317. 

diathetic, 312, 319. 

tuberculous, 312, 319. 

syphilitic, 312, 320. 

accidental, 312, 320. 

diagnosis, 313. 

prognosis, 315. 

morbid anatomy, 315. 

fibro-plastic, 320. 

osseous, 321. 

lipomatous, 321. 

enchondromatous, 321. 

mucous, 321. 

treatment, 322. 
Tumors of spinal cord, 517. 

symptoms, 517. 

causes, 520. 

diagnosis, 520. 

prognosis, 521. 

morbid anatomy, 621. 

pathology, 521. 

treatment, 521. 

Volitional insanity, 338, 357. 

Will, 328. 

Writer's spasm, 710. 

symptoms, 711. 

causes, 713. 

diagnosis, 713. 

prognosis, 714. 

morbid anatomy, 714. 

pathology, 714. 

treatment, 714. 



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THE PHYSIOLOGY 

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By HEJKTRY MAUDSLEY, ]VT. 13., London. 
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Part I.— The Physiology of the Mind. 

Chapter 1. On the Method of the Study of the Mind. 
" ' 2. The Mind and the Nervous System. 

" 3. The Spinal Cord, or Tertiary Nervous Centres ; or, Nervous Centres of Keflex Aetictn. 
" 4. Secondary Nervous Centres; or Sensory Ganglia; Sensorium Commune. 
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" 2. On the Insanity of Early Life. 
M 8. On the Varieties of Insanity. 



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" 5. On the Diagnosis of Insanity. 
" 6. On the Prognosis of Insanity. 



Chapter 7. On the Treatment of Insanity. 



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